Provider Demographics
NPI:1598993669
Name:ROBERTS, JENNIFER (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROBERTS
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 1:790 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 1:327 GUNDERSEN DR
Practice Address - Street 2:SUITE C
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2402
Practice Address - Country:US
Practice Address - Phone:630-784-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00859999OtherMEDICARE RR
IL212623005Medicare PIN
IL212989007Medicare PIN
IL213392004Medicare PIN
IL212622005Medicare PIN
IL202845044Medicare PIN
ILP00859999OtherMEDICARE RR
IL209796007Medicare PIN