Healthcare Provider Details

I. General information

NPI: 1952455537
Provider Name (Legal Business Name): JENNIFER ANN DYSZKIEWICZ MS, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W JEFFERSON BLVD SUITE 100
SOUTH BEND IN
46601-1994
US

IV. Provider business mailing address

1855 ALTGELD ST
SOUTH BEND IN
46614-1603
US

V. Phone/Fax

Practice location:
  • Phone: 574-289-4764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36000645A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: