Healthcare Provider Details

I. General information

NPI: 1912976929
Provider Name (Legal Business Name): JENNIFER MARIE MASTERSON PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE WHISLER PT, ATC

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5221 N BROADWAY ST
CHICAGO IL
60640-2303
US

IV. Provider business mailing address

4184 N CLARENDON AVE #1N
CHICAGO IL
60613-2227
US

V. Phone/Fax

Practice location:
  • Phone: 773-784-9406
  • Fax: 773-784-9401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-012420
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number070-012420
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070-012420
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-001603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: