Provider Demographics
NPI:1558611590
Name:KAMIENIAK, JENNIFER (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KAMIENIAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W GORDON TER UNIT 17B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2269
Mailing Address - Country:US
Mailing Address - Phone:773-255-3671
Mailing Address - Fax:
Practice Address - Street 1:720 W GORDON TER APT 17B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2263
Practice Address - Country:US
Practice Address - Phone:773-255-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07008354225100000X
IL070.018354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL82-3042381OtherTIN