Healthcare Provider Details

I. General information

NPI: 1114205770
Provider Name (Legal Business Name): JENNIFER L PENNINGTON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WINDSWEPT DR
NASHVILLE IL
62263
US

IV. Provider business mailing address

RR 3 BOX 837
FAIRFIELD IL
62837-9011
US

V. Phone/Fax

Practice location:
  • Phone: 618-237-2214
  • Fax: 618-327-9970
Mailing address:
  • Phone: 618-315-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070007159
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: