Provider Demographics
NPI:1790745958
Name:GOEKEN, JANE A (PT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:GOEKEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:A
Other - Last Name:BEHRENDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2810 FRANK SCOTT PARKWAY WEST
Mailing Address - Street 2:SUITE 824
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223
Mailing Address - Country:US
Mailing Address - Phone:618-234-9705
Mailing Address - Fax:618-257-0665
Practice Address - Street 1:209 NORTH CUMMINGS LANE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571
Practice Address - Country:US
Practice Address - Phone:309-886-2305
Practice Address - Fax:309-444-3893
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-009676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00991700OtherRR MEDICARE
ILK23460Medicare UPIN