Provider Demographics
NPI:1285794909
Name:LAFFERTY, JASON EUGENE (DC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:EUGENE
Last Name:LAFFERTY
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 1:206 N. MAIN AVE.
Mailing Address - Street 2:
Mailing Address - City:LADD
Mailing Address - State:IL
Mailing Address - Zip Code:61329-0833
Mailing Address - Country:US
Mailing Address - Phone:815-894-9400
Mailing Address - Fax:815-894-9403
Practice Address - Street 1:206 N. MAIN AVE.
Practice Address - Street 2:
Practice Address - City:LADD
Practice Address - State:IL
Practice Address - Zip Code:61329-0833
Practice Address - Country:US
Practice Address - Phone:815-894-9400
Practice Address - Fax:815-894-9403
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210653Medicare PIN
ILK13450Medicare PIN
ILU95616Medicare UPIN