Healthcare Provider Details

I. General information

NPI: 1972734861
Provider Name (Legal Business Name): JAMIE J FIFAREK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

515 KREITZER AVE
BLOOMINGTON IL
61701-5605
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8275
  • Fax: 309-662-7872
Mailing address:
  • Phone: 309-663-8275
  • Fax: 309-662-7872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070017206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: