Healthcare Provider Details

I. General information

NPI: 1265801724
Provider Name (Legal Business Name): JACQUELINE GEDDES PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

1452 N GREENVIEW AVE APT GF
CHICAGO IL
60642-7020
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7100
  • Fax:
Mailing address:
  • Phone: 612-232-3486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070020230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: