Provider Demographics
NPI:1376966242
Name:CAPPS, JENNA LYNN (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNN
Last Name:CAPPS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 LOTUS DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60073-1169
Mailing Address - Country:US
Mailing Address - Phone:224-627-8742
Mailing Address - Fax:
Practice Address - Street 1:567 N 5TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1903
Practice Address - Country:US
Practice Address - Phone:224-627-8743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001986A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer