Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 160.007734 | IL |
NPI | 1003383472 |
---|---|
Provider Name | Jennifer Renaud |
First Address | Hanover Park, IL 60133-4302 |
Second Address | Hanover Park, IL 60133-4302 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2018 |
Last Update Date | 24/10/2018 |