Provider Demographics
NPI:1730104639
Name:FERNANDEZ, JENNIFER M (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:21 US HIGWAY 41
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375
Practice Address - Country:US
Practice Address - Phone:219-803-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012582225100000X
IN05010965A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623066OtherBCBS PROVIDER NUMBER
IL1619908OtherBCBS IL GROUP NUMBER
IL367885100OtherUS DEPT OF LABOR
ILR02286Medicare PIN
IL568150Medicare PIN
ILCJ4383Medicare ID - Type UnspecifiedRAILROAD MEDICARE GRP
IL567700Medicare PIN
ILR02287Medicare PIN
IL1623066OtherBCBS PROVIDER NUMBER
IL367885100OtherUS DEPT OF LABOR
IL650021903Medicare PIN
ILL87357Medicare PIN
IL202542Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL568080Medicare PIN