Provider Demographics
NPI:1609121466
Name:SHURTZ, JENNIFER LEE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:SHURTZ
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:WEIDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:805 RUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4841
Mailing Address - Country:US
Mailing Address - Phone:217-619-1905
Mailing Address - Fax:
Practice Address - Street 1:3631 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4777
Practice Address - Country:US
Practice Address - Phone:217-535-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0026032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer