Provider Demographics
NPI:1134633621
Name:PISHOTTA, JENNIFER (DC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:PISHOTTA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-1008
Mailing Address - Country:US
Mailing Address - Phone:224-678-7334
Mailing Address - Fax:
Practice Address - Street 1:5608 SE 113TH ST STE A
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4069
Practice Address - Country:US
Practice Address - Phone:352-245-8955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013152111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor