Provider Demographics
NPI:1992900328
Name:NAKONECHNY, MARK JORDAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JORDAN
Last Name:NAKONECHNY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3825
Mailing Address - Country:US
Mailing Address - Phone:630-688-8169
Mailing Address - Fax:
Practice Address - Street 1:3900 PARADISE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-0931
Practice Address - Country:US
Practice Address - Phone:702-369-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1969225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist