Provider Demographics
NPI:1275784175
Name:MACK, MARY JO (KT)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:KT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 POPES CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1142
Mailing Address - Country:US
Mailing Address - Phone:847-548-5186
Mailing Address - Fax:
Practice Address - Street 1:3001 GREENBAY
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:847-688-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist