Provider Demographics
NPI:1477781599
Name:FORCK, JENNIFER ANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:FORCK
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 1:105 WOOD CT
Mailing Address - Street 2:APT 2
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-5516
Mailing Address - Country:US
Mailing Address - Phone:309-303-5548
Mailing Address - Fax:309-303-5548
Practice Address - Street 1:105 WOOD CT
Practice Address - Street 2:APT 2
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-5516
Practice Address - Country:US
Practice Address - Phone:309-303-5548
Practice Address - Fax:309-303-5548
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist