Basic Information
| Provider Information | |||||||||
| NPI: | 1760974232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | COHLMAN | ||||||||
| OtherFirstName: | JORDAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 924 W CUSTER AVE | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158445411 | ||||||||
| FaxNumber: | 8158445318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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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 | 070023714 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.