Provider Demographics
NPI:1669545489
Name:SIEGEL, JACLYN M (DPT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 1/2 WEST WRIGHTWOOD AVE.
Mailing Address - Street 2:APT. 2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-880-6925
Mailing Address - Fax:
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:BOX 76
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-880-6925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70014729225100000X
WI10390-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist