Provider Demographics
NPI:1790112092
Name:REYNOLDS-JENSEN, MARNIE (PT)
Entity Type:Individual
Prefix:
First Name:MARNIE
Middle Name:
Last Name:REYNOLDS-JENSEN
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 1:10402 SUTTON DALE LN
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2232
Mailing Address - Country:US
Mailing Address - Phone:630-878-3452
Mailing Address - Fax:
Practice Address - Street 1:9645 LINCOLNWAY LN
Practice Address - Street 2:SUITE 116
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1866
Practice Address - Country:US
Practice Address - Phone:815-464-0101
Practice Address - Fax:815-464-9191
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070006188OtherILLINOIS PHYSICAL THERAPIST LICENSE