Basic Information
| Provider Information | |||||||||
| NPI: | 1790745958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOEKEN | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BEHRENDS | ||||||||
| OtherFirstName: | JANE | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2810 FRANK SCOTT PARKWAY WEST | ||||||||
| Address2: | SUITE 824 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182349705 | ||||||||
| FaxNumber: | 6182570665 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 NORTH CUMMINGS LANE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098862305 | ||||||||
| FaxNumber: | 3094443893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 01/27/2012 | ||||||||
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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 | 070-009676 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00991700 | 01 | IL | RR MEDICARE | OTHER |