Provider Demographics
NPI:1700965944
Name:BUCCELLI, JENNIFER KATHLEEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:BUCCELLI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:KATHLEEN
Other - Last Name:WIEDLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:164 SUDA DRIVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:224-628-4411
Mailing Address - Fax:847-249-6593
Practice Address - Street 1:164 SUDA DRIVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:224-628-4411
Practice Address - Fax:847-249-6593
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist