Healthcare Provider Details

I. General information

NPI: 1790745958
Provider Name (Legal Business Name): JANE A GOEKEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE A BEHRENDS PT

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 NORTH CUMMINGS LANE
WASHINGTON IL
61571
US

IV. Provider business mailing address

2810 FRANK SCOTT PARKWAY WEST SUITE 824
BELLEVILLE IL
62223
US

V. Phone/Fax

Practice location:
  • Phone: 309-886-2305
  • Fax: 309-444-3893
Mailing address:
  • Phone: 618-234-9705
  • Fax: 618-257-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-009676
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: