Provider Demographics
NPI:1518347079
Name:TATE, JACLYN (DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:RAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
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 1:1323 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1207
Practice Address - Country:US
Practice Address - Phone:773-549-2520
Practice Address - Fax:773-549-2743
Is Sole Proprietor?:No
Enumeration Date:2015-05-31
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4918225100000X
IL070-022097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist