Provider Demographics
NPI:1275973828
Name:GRONEWOLD, JESSICA ELAINE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:GRONEWOLD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELAINE
Other - Last Name:EGGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 ROYAL BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4719
Practice Address - Country:US
Practice Address - Phone:847-931-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-12-02
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
ILF400102888Medicare PIN