Healthcare Provider Details

I. General information

NPI: 1346436821
Provider Name (Legal Business Name): JODI DESPOY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 W LAKE AVE STE 200
GLENVIEW IL
60026-1266
US

IV. Provider business mailing address

279 SCOTSCRAIG DR
VALPARAISO IN
46385-8006
US

V. Phone/Fax

Practice location:
  • Phone: 847-998-1188
  • Fax:
Mailing address:
  • Phone: 219-926-8387
  • Fax: 847-441-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002871A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: