Healthcare Provider Details

I. General information

NPI: 1740247394
Provider Name (Legal Business Name): JON A DEBORD PT MS ATC SCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E 10TH ST
KEWANEE IL
61443-1330
US

IV. Provider business mailing address

110 E 10TH ST
KEWANEE IL
61443-1330
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-2200
  • Fax: 309-852-2402
Mailing address:
  • Phone: 309-852-2200
  • Fax: 309-852-2402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070009875
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: