Provider Demographics
NPI:1699278341
Name:PLATA, JENSEN (BS, ATC)
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:
Last Name:PLATA
Suffix:
Gender:F
Credentials:BS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14265 W SHELLEY LN
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9550
Mailing Address - Country:US
Mailing Address - Phone:847-989-2377
Mailing Address - Fax:
Practice Address - Street 1:14265 W SHELLEY LN
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-9550
Practice Address - Country:US
Practice Address - Phone:847-989-2377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20000355732255A2300X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer