MEDICARE: JACQUELINE KONRAD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	160006956	IL

General Provider Information

NPI Number	:	1366834061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE KONRAD

Provider Business Mailing Address
First Line	:	1328 N LEAVITT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3026
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1328 N LEAVITT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3026
Country	:	US
Telephone Number	:	773-931-4072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2015
Last Update Date	:	03/04/2015

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Directions to “ JACQUELINE KONRAD ” Practice Location

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