Provider Demographics
NPI:1578999439
Name:WESTON, JACLYN K (PT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:K
Last Name:WESTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:K
Other - Last Name:BLANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
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:
Practice Address - Street 1:7224 118TH AVE
Practice Address - Street 2:STE E
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8424
Practice Address - Country:US
Practice Address - Phone:262-857-4400
Practice Address - Fax:262-857-4411
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12459-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100249753Medicare PIN
WIK400291944Medicare PIN
WIK400249860Medicare PIN