Provider Demographics
NPI:1992995070
Name:FOWLER, JASON CLEO (DC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:CLEO
Last Name:FOWLER
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 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:STE 301N
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-320-6400
Mailing Address - Fax:630-701-1007
Practice Address - Street 1:7440 WOODWARD AVE
Practice Address - Street 2:SUITE K
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2657
Practice Address - Country:US
Practice Address - Phone:630-324-4960
Practice Address - Fax:630-324-4965
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010938111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000000570383OtherANTHEM BCBS
MOP00655474OtherRR MEDICARE
IL217108002Medicare PIN
MOMA1173001Medicare PIN