Provider Demographics
NPI:1861639684
Name:TILTON, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:TILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7722 GREENWAY BLVD
Mailing Address - Street 2:UNIT 1SE
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-5580
Mailing Address - Country:US
Mailing Address - Phone:815-690-1112
Mailing Address - Fax:
Practice Address - Street 1:7722 GREENWAY BLVD
Practice Address - Street 2:UNIT 1SE
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-5580
Practice Address - Country:US
Practice Address - Phone:815-690-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist