MEDICARE: JEZREEL TREVORAH PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305217552	VA
2	225100000X	Physical Therapist	1385471	TX

General Provider Information

NPI Number	:	1700661162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEZREEL TREVORAH PT, DPT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:	630-575-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	6049 HARBOUR PARK DR
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2160
Country	:	US
Telephone Number	:	804-639-2359
Fax Number	:	804-639-2029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2023
Last Update Date	:	02/25/2026

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