Provider Demographics
NPI:1124754593
Name:FULKS, JENNA M (PT, DPT)
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:M
Last Name:FULKS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:997 N CORPORATE CIR STE B
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7822
Mailing Address - Country:US
Mailing Address - Phone:847-223-8001
Mailing Address - Fax:
Practice Address - Street 1:997 N CORPORATE CIR STE B
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7822
Practice Address - Country:US
Practice Address - Phone:847-223-8001
Practice Address - Fax:847-986-3580
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0267392251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic