Provider Demographics
NPI:1447315155
Name:MIYAMOTO, JAN AH-OI KAINOA (PT, DPT)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:AH-OI KAINOA
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9027 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2458
Mailing Address - Country:US
Mailing Address - Phone:847-894-1371
Mailing Address - Fax:
Practice Address - Street 1:755 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2805
Practice Address - Country:US
Practice Address - Phone:847-272-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist