Provider Demographics
NPI:1326008889
Name:HART, JENNIFER E (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:HART
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62663-0144
Mailing Address - Country:US
Mailing Address - Phone:217-587-9205
Mailing Address - Fax:
Practice Address - Street 1:901 W MORTON AVE
Practice Address - Street 2:SUITE 16A
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3146
Practice Address - Country:US
Practice Address - Phone:217-245-4640
Practice Address - Fax:217-245-4642
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LINCOLN LAND COMMUNIOtherSCHOOL