Provider Demographics
NPI:1114688892
Name:FARTHING, JENNIFER NICOLE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:FARTHING
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:BAUERSACHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:4715 FOXTAIL LN
Mailing Address - Street 2:
Mailing Address - City:TAMAROA
Mailing Address - State:IL
Mailing Address - Zip Code:62888-2251
Mailing Address - Country:US
Mailing Address - Phone:618-559-0169
Mailing Address - Fax:
Practice Address - Street 1:3331 W DEYOUNG ST STE 101
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5896
Practice Address - Country:US
Practice Address - Phone:618-559-0169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960036132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer