Provider Demographics
NPI:1245530609
Name:DE JONG, ELISA MARIE (CO)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIE
Last Name:DE JONG
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N CHILDRENS PLZ
Mailing Address - Street 2:BOX #46
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3363
Mailing Address - Country:US
Mailing Address - Phone:773-327-1022
Mailing Address - Fax:773-327-1054
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:BOX #46
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-327-1022
Practice Address - Fax:773-327-1054
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist