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General NPI Number Information
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NPI Number | 1184265589
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Entity Type | Individual
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Provider Name | JOVAN PLUNKETT LMT
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Gender | Male
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Dates
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Enumeration Date | 10/07/2019
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Last Update Date | 10/07/2019
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Provider Practice Location Address
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Address Line | 4019 183RD ST
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City | COUNTRY CLUB HILLS
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State | IL
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Zip | 60478-5306
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Country | US
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Telephone | 708-573-2963
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Fax |
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Provider Business Mailing Address
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Address Line | 710 BRADLEY AVE
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City | MATTESON
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State | IL
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Zip | 60443-1605
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Country | US
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Telephone | 708-573-2963
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 227.020475
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License Number State | IL
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