Provider Demographics
NPI:1003383472
Name:RENAUD, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RENAUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-4302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 W LAKE ST
Practice Address - Street 2:
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133-4302
Practice Address - Country:US
Practice Address - Phone:630-556-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007734225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant