Provider Demographics
NPI:1467169797
Name:DESJARDINE, SAMANTHA JUDITH (MSED LAT ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JUDITH
Last Name:DESJARDINE
Suffix:
Gender:F
Credentials:MSED LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 COPLEY ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3248
Mailing Address - Country:US
Mailing Address - Phone:630-818-0517
Mailing Address - Fax:
Practice Address - Street 1:100 SPALDING DR STE 300
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6553
Practice Address - Country:US
Practice Address - Phone:630-790-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0048392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer