=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467770651
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JODI L KLEMM PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2010
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 593 COLLIER DR
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60002-8913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-818-1182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 593 COLLIER DR.
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60002-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-818-1182
-----------------------------------------------------
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 | 160-003144
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1052-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------