Provider Demographics
NPI:1588773352
Name:DAVIS, JEROLD E (PT, OCS)
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17517 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6501
Mailing Address - Country:US
Mailing Address - Phone:708-429-4814
Mailing Address - Fax:708-429-9174
Practice Address - Street 1:17517 80TH AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6501
Practice Address - Country:US
Practice Address - Phone:708-429-4814
Practice Address - Fax:708-429-9174
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL0700060192251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1588773352OtherNPI
IL070006019OtherLICENSE #