Provider Demographics
NPI:1104071067
Name:ZIMMERMAN, JESSICA ANN (MPT)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ANN
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:916 TALON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:916 TALON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1848
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008034460225100000X
IL070017452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207465010Medicare PIN