Provider Demographics
NPI:1255390266
Name:ADOLPH, JASON TODD (MS, LAT ATC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:TODD
Last Name:ADOLPH
Suffix:
Gender:M
Credentials:MS, LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 OAKWOOD DR
Mailing Address - Street 2:APT #2M
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3085
Mailing Address - Country:US
Mailing Address - Phone:630-631-7990
Mailing Address - Fax:
Practice Address - Street 1:972 BROOK FOREST AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60431-8807
Practice Address - Country:US
Practice Address - Phone:815-439-4938
Practice Address - Fax:630-439-7816
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer