Healthcare Provider Details

I. General information

NPI: 1144095373
Provider Name (Legal Business Name): EWA JANKUC PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 W. GRAND AVENUE
CHICAGO IL
60654
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 872-304-1600
  • Fax: 872-304-1601
Mailing address:
  • Phone: 586-350-2644
  • Fax: 586-541-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.010004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: