=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396436010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER VANKO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16655 W KELLY RD
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60083-9639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-525-1470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16655 W KELLY RD
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60083-9639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-525-1470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 3138-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 160.009079
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------