Provider Demographics
NPI:1215986021
Name:WOOKEY, JACOB DALE (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DALE
Last Name:WOOKEY
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 1:1615 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61085-9126
Mailing Address - Country:US
Mailing Address - Phone:815-947-3320
Mailing Address - Fax:815-947-3380
Practice Address - Street 1:630 TERRA WEST DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4536
Practice Address - Country:US
Practice Address - Phone:815-235-7858
Practice Address - Fax:815-235-7913
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06885111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210296OtherMEDICARE GROUP
IL08982007OtherBCBS GROUP
IL038011028Medicaid
ILK45769Medicare PIN
IL08982007OtherBCBS GROUP