Provider Demographics
NPI:1821328733
Name:JACKSON, BERNADETTE CADIZ (DPT)
Entity Type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:CADIZ
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:BERNADETTE
Other - Middle Name:OBSEQUIO
Other - Last Name:CADIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:4501 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-0407
Mailing Address - Country:US
Mailing Address - Phone:417-793-9848
Mailing Address - Fax:
Practice Address - Street 1:500 MCHENRY RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089
Practice Address - Country:US
Practice Address - Phone:847-537-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009002317225100000X
IL070019779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty