Provider Demographics
NPI:1114035045
Name:RACETTE, JENNIFER NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:RACETTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 E PORTER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9111
Mailing Address - Country:US
Mailing Address - Phone:219-926-5850
Mailing Address - Fax:219-250-2072
Practice Address - Street 1:751 E PORTER AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9111
Practice Address - Country:US
Practice Address - Phone:219-926-5850
Practice Address - Fax:219-250-2072
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0148712251X0800X
IN05012457A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26296Medicare ID - Type Unspecified