Provider Demographics
NPI:1003058215
Name:BUNAG, JENNIFER ABIGAIL (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ABIGAIL
Last Name:BUNAG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 ASPEN LN APT 6
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-3317
Mailing Address - Country:US
Mailing Address - Phone:630-915-0533
Mailing Address - Fax:
Practice Address - Street 1:6704 ASPEN LN APT 6
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-3317
Practice Address - Country:US
Practice Address - Phone:630-915-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005013225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant