Provider Demographics
NPI:1265817464
Name:PENDERGAST, JENNIFER LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:GIVENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:411 E CONGRESS PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6247
Mailing Address - Country:US
Mailing Address - Phone:815-455-8213
Mailing Address - Fax:815-455-8219
Practice Address - Street 1:411 E CONGRESS PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6247
Practice Address - Country:US
Practice Address - Phone:815-455-8213
Practice Address - Fax:815-455-8219
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012669111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor