Provider Demographics
NPI:1023107422
Name:DIGIACOMO, JACLYN M (LPT)
Entity type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:M
Last Name:DIGIACOMO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1331
Mailing Address - Country:US
Mailing Address - Phone:773-282-6648
Mailing Address - Fax:773-282-6965
Practice Address - Street 1:5545 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1331
Practice Address - Country:US
Practice Address - Phone:773-282-6648
Practice Address - Fax:773-282-6965
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK32728Medicare PIN