=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790112092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARNIE REYNOLDS-JENSEN P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2013
-----------------------------------------------------
Last Update Date | 10/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9645 LINCOLNWAY LN SUITE 116
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-1866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-464-0101
-----------------------------------------------------
Fax | 815-464-9191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10402 SUTTON DALE LN
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-2232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-878-3452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070006188
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------