Provider Demographics
NPI:1669843553
Name:BUDWITIS, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BUDWITIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7758 NORTHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-3119
Mailing Address - Country:US
Mailing Address - Phone:708-209-0402
Mailing Address - Fax:
Practice Address - Street 1:7758 NORTHFIELD LN
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-3119
Practice Address - Country:US
Practice Address - Phone:708-209-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-17
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.001392225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist