Healthcare Provider Details

I. General information

NPI: 1114407285
Provider Name (Legal Business Name): JENNA RAE URBANIAK I PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2018
Last Update Date: 08/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 W IRVING PARK RD
CHICAGO IL
60613-2407
US

IV. Provider business mailing address

1921 W IRVING PARK RD
CHICAGO IL
60613-2407
US

V. Phone/Fax

Practice location:
  • Phone: 773-687-9442
  • Fax: 888-733-1772
Mailing address:
  • Phone: 773-687-9442
  • Fax: 888-733-1772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070023822
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: