Healthcare Provider Details

I. General information

NPI: 1134489578
Provider Name (Legal Business Name): KATHRYN E BJERKE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11248 WALTON DR
ROSCOE IL
61073-8122
US

IV. Provider business mailing address

11248 WALTON DR
ROSCOE IL
61073-8122
US

V. Phone/Fax

Practice location:
  • Phone: 815-623-1569
  • Fax:
Mailing address:
  • Phone: 815-623-1569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227013165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: