Healthcare Provider Details

I. General information

NPI: 1033158761
Provider Name (Legal Business Name): VICKI LYNN RUDH JONES P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICKI LYNN WILSON P.T.

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 OSPREY RDG
MACHESNEY PARK IL
61115-8364
US

IV. Provider business mailing address

283 OSPREY RDG
MACHESNEY PARK IL
61115-8364
US

V. Phone/Fax

Practice location:
  • Phone: 815-623-9200
  • Fax: 815-623-9200
Mailing address:
  • Phone: 815-623-9200
  • Fax: 815-623-9200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070010001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: