Provider Demographics
NPI:1073877361
Name:SALMON, JENNIFER LEE (PTA,ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:SALMON
Suffix:
Gender:F
Credentials:PTA,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-7525
Mailing Address - Country:US
Mailing Address - Phone:309-449-4501
Mailing Address - Fax:
Practice Address - Street 1:107 TREMONT ST
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747-7525
Practice Address - Country:US
Practice Address - Phone:309-449-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02495225200000X
IL0960020302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant