Provider Demographics
NPI:1841274990
Name:JENCKES, KIMBERLY ANNE (ATC)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:JENCKES
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 GREGORY ST
Mailing Address - Street 2:UNIT E
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-2077
Mailing Address - Country:US
Mailing Address - Phone:708-638-2675
Mailing Address - Fax:
Practice Address - Street 1:1137 N EOLA RD
Practice Address - Street 2:SUITE 106
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-7096
Practice Address - Country:US
Practice Address - Phone:630-236-6698
Practice Address - Fax:630-236-6856
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer