Provider Demographics
NPI:1396104089
Name:NYDER, JENNIFER MARIE (DT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:NYDER
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 WATER CHASE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-4813
Mailing Address - Country:US
Mailing Address - Phone:708-307-5462
Mailing Address - Fax:708-221-7173
Practice Address - Street 1:2125 WATER CHASE DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-4813
Practice Address - Country:US
Practice Address - Phone:708-307-5462
Practice Address - Fax:708-221-7173
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist