Provider Demographics
NPI:1306821046
Name:WATKIN, JEFFREY (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:WATKIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:J
Other - Last Name:WATKIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:700 FLORSHEIM DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5000
Mailing Address - Country:US
Mailing Address - Phone:847-367-7131
Mailing Address - Fax:
Practice Address - Street 1:700 FLORSHEIM DR
Practice Address - Street 2:SUITE 12
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5000
Practice Address - Country:US
Practice Address - Phone:847-367-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Not Answered111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210837Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILK14254Medicare ID - Type UnspecifiedMEDICARE ID#
ILT37690Medicare UPIN