Provider Demographics
NPI:1922754191
Name:HENNESSY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S LAFLIN ST APT 617
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 S LAFLIN ST APT 617
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2440
Practice Address - Country:US
Practice Address - Phone:312-806-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006758225200000X
IL225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant