Provider Demographics
NPI:1831216555
Name:MATARAZZO, JENNIFER CACCOMO (DPT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:CACCOMO
Last Name:MATARAZZO
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 1:4139 N FIRESTONE CT
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60192-1701
Mailing Address - Country:US
Mailing Address - Phone:847-525-9556
Mailing Address - Fax:847-220-9206
Practice Address - Street 1:4139 N FIRESTONE CT
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60192-1701
Practice Address - Country:US
Practice Address - Phone:847-525-9556
Practice Address - Fax:847-220-9206
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700156362251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617235OtherBLUE CROSS BLUE SHIELD