Provider Demographics
NPI:1275894321
Name:BERENYI, JACQUI (PT)
Entity Type:Individual
Prefix:
First Name:JACQUI
Middle Name:
Last Name:BERENYI
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 1:409 W COMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:SHABBONA
Mailing Address - State:IL
Mailing Address - Zip Code:60550-9790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 W COMANCHE AVE
Practice Address - Street 2:
Practice Address - City:SHABBONA
Practice Address - State:IL
Practice Address - Zip Code:60550-9790
Practice Address - Country:US
Practice Address - Phone:815-824-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.018783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist