Basic Information
| Provider Information | |||||||||
| NPI: | 1003149444 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BENNETT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | PT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 506 E SOUTHWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656260299 | ||||||||
| FaxNumber: | 7658642070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05010397A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 36001638A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.