Provider Demographics
NPI:1720681638
Name:CHANGELON, JAKE P (DC)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:P
Last Name:CHANGELON
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 1:10705 RUTH RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-7156
Mailing Address - Country:US
Mailing Address - Phone:815-342-7167
Mailing Address - Fax:
Practice Address - Street 1:10705 RUTH RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-7156
Practice Address - Country:US
Practice Address - Phone:815-342-7167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38013625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor