Provider Demographics
NPI:1053639641
Name:SIPULA, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SIPULA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WICKAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:211 E HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1811
Mailing Address - Country:US
Mailing Address - Phone:618-588-4000
Mailing Address - Fax:618-588-4800
Practice Address - Street 1:211 E HANOVER ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1811
Practice Address - Country:US
Practice Address - Phone:618-588-4000
Practice Address - Fax:618-588-4800
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018251225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist