Provider Demographics
NPI:1982941738
Name:CONNOLLY, JENINE RENEE (LMT)
Entity type:Individual
Prefix:
First Name:JENINE
Middle Name:RENEE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JENINE
Other - Middle Name:RENEE
Other - Last Name:SHERIDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2518 CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1311
Mailing Address - Country:US
Mailing Address - Phone:815-302-3018
Mailing Address - Fax:
Practice Address - Street 1:2518 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1311
Practice Address - Country:US
Practice Address - Phone:815-302-3018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003187225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist