Basic Information
| Provider Information | |||||||||
| NPI: | 1528590619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMLER | ||||||||
| FirstName: | JACKSON | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1648 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974401648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424384 | ||||||||
| FaxNumber: | 5414632820 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736656730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 11/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | DO207019 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.