Provider Demographics
NPI:1124318415
Name:JACONO, KRISTIN PUPA (DPT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:PUPA
Last Name:JACONO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:2943 RIVERSIDE DR STE D
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-3437
Practice Address - Country:US
Practice Address - Phone:434-799-7732
Practice Address - Fax:434-799-7733
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6227225100000X
MD23775225100000X
VA2305206860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist