MEDICARE: MRS. JENNIFER MARIE MASTERSON PT, ATC

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	225100000X	Physical Therapist	070-012420	IL
2	2251S0007X	Sports Physical Therapist	070-012420	IL
3	2251X0800X	Orthopedic Physical Therapist	070-012420	IL
4	2255A2300X	Athletic Trainer	096-001603	IL

General Provider Information

NPI Number	:	1912976929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER MARIE MASTERSON PT, ATC

Provider Business Mailing Address
First Line	:	4184 N CLARENDON AVE
Second Line	:	#1N
City	:	CHICAGO
State	:	IL
Zip	:	60613-2227
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5221 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2303
Country	:	US
Telephone Number	:	773-784-9406
Fax Number	:	773-784-9401

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2015

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