Provider Demographics
NPI:1285074187
Name:KELLEY, JESSICA C (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WITTHOFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:900 E WALNUT ST STE 1
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3132
Practice Address - Country:US
Practice Address - Phone:618-319-7540
Practice Address - Fax:618-319-7542
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028761225100000X
IL070021414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist