Basic Information
| Provider Information | |||||||||
| NPI: | 1578999439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTON | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BLANK | ||||||||
| OtherFirstName: | JACLYN | ||||||||
| OtherMiddleName: | K. | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7224 118TH AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531428424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628574400 | ||||||||
| FaxNumber: | 2628574411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12459-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.