Healthcare Provider Details

I. General information

NPI: 1053639641
Provider Name (Legal Business Name): JENNIFER SIPULA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER WICKAM PT

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E HANOVER ST
NEW BADEN IL
62265-1811
US

IV. Provider business mailing address

211 E HANOVER ST
NEW BADEN IL
62265-1811
US

V. Phone/Fax

Practice location:
  • Phone: 618-588-4000
  • Fax: 618-588-4800
Mailing address:
  • Phone: 618-588-4000
  • Fax: 618-588-4800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070018251
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: