Healthcare Provider Details

I. General information

NPI: 1568687200
Provider Name (Legal Business Name): JINEANE BLACK HEYBECK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S RIVERSIDE PLZ SUITE 830
CHICAGO IL
60606-5808
US

IV. Provider business mailing address

415 E NORTH WATER ST #703
CHICAGO IL
60611-5594
US

V. Phone/Fax

Practice location:
  • Phone: 866-386-0773
  • Fax: 312-627-2700
Mailing address:
  • Phone: 312-755-0831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05002361A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: