Provider Demographics
NPI:1063775443
Name:LEWIS, JESSICA (MPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 COUNTY ROAD 2100 N
Mailing Address - Street 2:
Mailing Address - City:CISNE
Mailing Address - State:IL
Mailing Address - Zip Code:62823-7808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 STACEY BURK DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-3241
Practice Address - Country:US
Practice Address - Phone:618-662-8060
Practice Address - Fax:618-662-8080
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.013027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist