Provider Demographics
NPI:1841239530
Name:BURBAGE, JENNIFER R (MSPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:BURBAGE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:JENNFIER
Other - Middle Name:R
Other - Last Name:SADOWSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1738 165TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2821
Practice Address - Country:US
Practice Address - Phone:219-844-1782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006912A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000324517OtherANTHEM - MBWOUDE
IN000000300593OtherANTHEM - APT PLUS
IN000000325382OtherANTHEM - 1ST AID PLUS
INP00144862Medicare ID - Type UnspecifiedRR MED - MBWOUDE
INM400014780Medicare PIN
IN000000300593OtherANTHEM - APT PLUS
INP00259762Medicare ID - Type UnspecifiedRR MED - APT PLUS
IN214690JMedicare ID - Type UnspecifiedPART B GROUP MEMBER
INM400052235Medicare PIN
IN000000324517OtherANTHEM - MBWOUDE