Provider Demographics
NPI:1962780775
Name:LOOS, SALLY JO (DC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:LOOS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W CORNELIA AVE
Mailing Address - Street 2:309
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2756
Mailing Address - Country:US
Mailing Address - Phone:319-621-5428
Mailing Address - Fax:
Practice Address - Street 1:535 W CORNELIA AVE
Practice Address - Street 2:309
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2756
Practice Address - Country:US
Practice Address - Phone:319-621-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011999111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor