Provider Demographics
NPI:1407306848
Name:HENNEBERG, JENNIFER
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:HENNEBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COVE POINTE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1417
Mailing Address - Country:US
Mailing Address - Phone:309-645-9527
Mailing Address - Fax:
Practice Address - Street 1:135 N WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3528
Practice Address - Country:US
Practice Address - Phone:309-664-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007198225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant