Provider Demographics
NPI:1609244813
Name:BENTLEY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SCHRAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2136 VADALABENE DR
Practice Address - Street 2:SUITE D
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5828
Practice Address - Country:US
Practice Address - Phone:618-288-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist