Provider Demographics
NPI:1275829244
Name:JAIN, AMY S (DPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:JAIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:A
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:1757 NORTHWIND BLVD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-9617
Practice Address - Country:US
Practice Address - Phone:224-206-0200
Practice Address - Fax:224-206-0201
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01014355OtherMCRR
ILP01014355OtherMCRR