Provider Demographics
NPI:1255654950
Name:DE LARA, JENIFER CARLOS (PT)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:CARLOS
Last Name:DE LARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 SHERMAN AVENUE #605
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:773-817-2522
Mailing Address - Fax:
Practice Address - Street 1:1415 SHERMAN AVE
Practice Address - Street 2:APT. 605
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4453
Practice Address - Country:US
Practice Address - Phone:773-817-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-0090352251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics