Healthcare Provider Details

I. General information

NPI: 1245700996
Provider Name (Legal Business Name): JINKYNICOLE CO LAYUG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13951 W GRAND AVE
SURPRISE AZ
85374-2436
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 623-537-9730
  • Fax:
Mailing address:
  • Phone: 866-370-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-035010
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: