Basic Information
| Provider Information | |||||||||
| NPI: | 1679812697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNUTH | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | COURTNEY | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | NAWROCKI | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | COURTNEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10860 HIGHLAND RD | ||||||||
| Address2: | |||||||||
| City: | HARTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483532629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106321000 | ||||||||
| FaxNumber: | 8106321001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 07/25/2014 | ||||||||
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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 | 5501016200 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.