Provider Demographics
NPI:1962822635
Name:ST JEAN, DAVID (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ST JEAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N DEARBORN ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3873
Mailing Address - Country:US
Mailing Address - Phone:312-869-9780
Mailing Address - Fax:
Practice Address - Street 1:650 N DEARBORN ST
Practice Address - Street 2:SUITE 800
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3873
Practice Address - Country:US
Practice Address - Phone:312-869-9780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038012533OtherIL LICENSE
IL4653455136OtherTAX IDENTIFICATION