Healthcare Provider Details

I. General information

NPI: 1417463639
Provider Name (Legal Business Name): TERTIA ABIGAIL JEPPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E. ERIE ST.
CHICAGO IL
60611-2654
US

IV. Provider business mailing address

1902 2ND ST
PERU IL
61354-3306
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax:
Mailing address:
  • Phone: 815-993-1280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.004708
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: