=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396003083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. JENNIFER KUJAWSKI, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2012
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 742 N MARKET ST SUITE D
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62298-1079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-939-4110
-----------------------------------------------------
Fax | 618-939-4116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 742 N MARKET ST SUITE D
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62298-1079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-939-4110
-----------------------------------------------------
Fax | 618-939-4116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. JENNIFER KUJAWSKI
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 618-939-4110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038011414
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------