Provider Demographics
NPI:1003149444
Name:BENNETT, JEFFREY R JR (PT, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:506 E SOUTHWAY BLVD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902
Practice Address - Country:US
Practice Address - Phone:765-626-0299
Practice Address - Fax:765-864-2070
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010397A225100000X
IN36001638A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI555850029Medicare UPIN