Healthcare Provider Details

I. General information

NPI: 1962094201
Provider Name (Legal Business Name): ELIZABETH JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W MADISON ST STE 2
CHICAGO IL
60607-2055
US

IV. Provider business mailing address

1600 S CLINTON ST
CHICAGO IL
60616-1110
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-1042
  • Fax:
Mailing address:
  • Phone: 312-330-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: