Provider Demographics
NPI:1144587973
Name:JG JOHNSON CHIROPRACTIC OFFICE PC
Entity type:Organization
Organization Name:JG JOHNSON CHIROPRACTIC OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-662-3410
Mailing Address - Street 1:20 TOWER CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5711
Mailing Address - Country:US
Mailing Address - Phone:847-662-3410
Mailing Address - Fax:847-662-3477
Practice Address - Street 1:20 TOWER CT
Practice Address - Street 2:SUITE B
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5711
Practice Address - Country:US
Practice Address - Phone:847-662-3410
Practice Address - Fax:847-662-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-004181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL638030Medicare UPIN