Provider Demographics
NPI:1720090830
Name:DEATHERAGE, JENELLE (PT)
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:9901 N KNOXVILLE AVE
Practice Address - Street 2:STE D
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1429
Practice Address - Country:US
Practice Address - Phone:309-243-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7357225100000X
IL070020706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070020706OtherILLINOIS PT LICENSE NO.