Provider Demographics
NPI:1295935062
Name:THEISEN, JENNIFER MARIE (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:THEISEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KREMA
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:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:800 DES PLAINES AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2035
Practice Address - Country:US
Practice Address - Phone:708-366-2442
Practice Address - Fax:708-366-0179
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-015945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00471771Medicare PIN
IL216859003Medicare PIN
IL202845001Medicare PIN
IL202845158Medicare PIN
ILK41388Medicare PIN