Provider Demographics
NPI:1528367018
Name:MIX, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SCHACHNER
Other - Suffix:
Other - Last Name Type:Former Name
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:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:335 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1357
Practice Address - Country:US
Practice Address - Phone:630-238-7940
Practice Address - Fax:630-238-9053
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-018356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist