Provider Demographics
NPI:1205393931
Name:HAYES, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HAYES
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 1:9 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-9572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 WALNUT ST
Practice Address - Street 2:
Practice Address - City:EAST DUBUQUE
Practice Address - State:IL
Practice Address - Zip Code:61025-9572
Practice Address - Country:US
Practice Address - Phone:815-281-2043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
IA098028225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant