Provider Demographics
NPI:1306828645
Name:ANDERSON, JAY PATRICK (ATC)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:PATRICK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 CORRINE AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5161
Mailing Address - Country:US
Mailing Address - Phone:815-356-0456
Mailing Address - Fax:847-628-1591
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1404
Practice Address - Country:US
Practice Address - Phone:847-628-1592
Practice Address - Fax:847-628-1591
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL960006012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer