Healthcare Provider Details

I. General information

NPI: 1508212374
Provider Name (Legal Business Name): JAKOB AWENDER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3973 W ALGONQUIN RD
ALGONQUIN IL
60102-9700
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 224-348-7600
  • Fax: 224-348-7601
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070022241
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number070022241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: