Provider Demographics
NPI:1184265589
Name:PLUNKETT, JOVAN (LMT)
Entity type:Individual
Prefix:
First Name:JOVAN
Middle Name:
Last Name:PLUNKETT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 BRADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1605
Mailing Address - Country:US
Mailing Address - Phone:708-573-2963
Mailing Address - Fax:
Practice Address - Street 1:4019 183RD ST
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-5306
Practice Address - Country:US
Practice Address - Phone:708-573-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.020475225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist