Provider Demographics
NPI:1760877807
Name:DZIEKAN, JILL (LMT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:DZIEKAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 LESTER DR
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-9489
Mailing Address - Country:US
Mailing Address - Phone:708-715-5681
Mailing Address - Fax:815-469-7360
Practice Address - Street 1:1309 LESTER DR
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-9489
Practice Address - Country:US
Practice Address - Phone:708-715-5681
Practice Address - Fax:815-469-7360
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227015133225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist