Provider Demographics
NPI:1992716930
Name:JENDRA, LAURA (DC)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:JENDRA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10761 163RD PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8861
Mailing Address - Country:US
Mailing Address - Phone:708-403-9450
Mailing Address - Fax:708-403-9488
Practice Address - Street 1:10761 163RD PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8861
Practice Address - Country:US
Practice Address - Phone:708-403-9450
Practice Address - Fax:708-403-9488
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008780111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213468Medicare UPIN