Provider Demographics
NPI:1962270702
Name:WALCZAK, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13205 W CHAPLIN ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13205 W CHAPLIN ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-8624
Practice Address - Country:US
Practice Address - Phone:847-863-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist