Provider Demographics
NPI:1104121904
Name:WALLENBERG, JENNIFER LYNN (PT, DPT, PCS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:WALLENBERG
Suffix:
Gender:F
Credentials:PT, DPT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62293-1305
Mailing Address - Country:US
Mailing Address - Phone:708-465-2200
Mailing Address - Fax:
Practice Address - Street 1:127 W BROADWAY
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:IL
Practice Address - Zip Code:62293-1305
Practice Address - Country:US
Practice Address - Phone:708-465-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070.017195225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist