Provider Demographics
NPI:1669624482
Name:KNUTSON, JACLYN ANN (DPT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANN
Last Name:KNUTSON
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 1:1203 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6408
Mailing Address - Country:US
Mailing Address - Phone:773-519-1044
Mailing Address - Fax:
Practice Address - Street 1:1865 E BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2218
Practice Address - Country:US
Practice Address - Phone:847-805-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist