Healthcare Provider Details

I. General information

NPI: 1306365150
Provider Name (Legal Business Name): JENDAYI WATKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 HALF DAY RD
DEERFIELD IL
60015-1241
US

IV. Provider business mailing address

1620 LABONTE PKWY
MCDONOUGH GA
30253-8124
US

V. Phone/Fax

Practice location:
  • Phone: 630-487-9241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: