Provider Demographics
NPI:1447476205
Name:FASEN, JO M (MPT, OCS, CSCS, MDT)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:M
Last Name:FASEN
Suffix:
Gender:F
Credentials:MPT, OCS, CSCS, MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 N STATE ST
Mailing Address - Street 2:36D
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-5476
Mailing Address - Country:US
Mailing Address - Phone:312-926-5772
Mailing Address - Fax:312-695-2772
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 17-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-6800
Practice Address - Fax:312-695-2771
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist