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NPI Code Detail

MEDICARE: MISS JENNIFER JO GIDLEY MPT

MEDICARE: MISS JENNIFER JO GIDLEY MPT
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
1225100000XPhysical Therapist070-010487IL

General Provider Information

NPI Number : 1730131152
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS JENNIFER JO GIDLEY MPT
Provider Business Mailing Address
First Line : 4121 VETERANS MEMORIAL DR
Second Line :
City : MOUNT VERNON
State : IL
Zip : 62864-6262
Country : US
Telephone Number : 618-242-8887
Fax Number : 618-242-2551
Provider Business Practice Location Address
First Line : 4121 VETERANS MEMORIAL DR
Second Line :
City : MOUNT VERNON
State : IL
Zip : 62864-6262
Country : US
Telephone Number : 618-242-8887
Fax Number : 618-242-2551
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/16/2006
Last Update Date : 07/09/2007

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