Provider Demographics
NPI:1497926679
Name:SRIDHAR, JAYANTHI (PT)
Entity Type:Individual
Prefix:
First Name:JAYANTHI
Middle Name:
Last Name:SRIDHAR
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 RAYMOND DR
Practice Address - Street 2:SUITE 105
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9789
Practice Address - Country:US
Practice Address - Phone:630-355-5255
Practice Address - Fax:630-355-5207
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016264225100000X
IL160-003673225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202845004Medicare PIN
IL216859005Medicare PIN
ILK51047Medicare PIN