Provider Demographics
NPI:1871829820
Name:DWYER, JANE LOIS (PT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:LOIS
Last Name:DWYER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:LOIS
Other - Last Name:CAREY-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:665 W. JACKSON
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3187
Mailing Address - Country:US
Mailing Address - Phone:815-334-8850
Mailing Address - Fax:815-334-8853
Practice Address - Street 1:665 W. JACKSON
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3187
Practice Address - Country:US
Practice Address - Phone:815-334-8850
Practice Address - Fax:815-334-8853
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-003243208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL482668261001Medicaid
IL202272Medicare PIN