Provider Demographics
NPI:1972734861
Name:FIFAREK, JAMIE J (DPT)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:J
Last Name:FIFAREK
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 1:515 KREITZER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5605
Mailing Address - Country:US
Mailing Address - Phone:309-663-8275
Mailing Address - Fax:309-662-7872
Practice Address - Street 1:2404 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3630
Practice Address - Country:US
Practice Address - Phone:309-663-8275
Practice Address - Fax:309-662-7872
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700172062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics