Provider Demographics
NPI:1497701775
Name:KLACKO, JAIME (PT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:KLACKO
Suffix:
Gender:F
Credentials:PT
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 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1206 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-2404
Practice Address - Country:US
Practice Address - Phone:630-967-2000
Practice Address - Fax:630-303-5859
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931529OtherMEDICARE RAILROAD
ILK49937Medicare PIN
ILP00931529OtherMEDICARE RAILROAD
ILK17545Medicare ID - Type Unspecified
ILP00651156Medicare PIN
IL216859154Medicare PIN
ILQ39625Medicare UPIN
IL216859012Medicare PIN
IL202845175Medicare PIN