Basic Information
| Provider Information | |||||||||
| NPI: | 1144251661 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307593251 | ||||||||
| Practice Location | |||||||||
| Address1: | 1812 MARSH RD | ||||||||
| Address2: | STORE 505 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198104581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024757500 | ||||||||
| FaxNumber: | 3024754581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J10001506 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 221722076 | 01 | CHAMPUS | OTHER | 2286951000 | 01 | IBC | OTHER | 62071807 | 01 | MD | CAREFIRST | OTHER | 62071807 | 01 | CAREFIRST | OTHER |