Healthcare Provider Details

I. General information

NPI: 1154831725
Provider Name (Legal Business Name): JONATHAN OPPERMAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2338 W VAN WINKLE WAY STE 3100
PEORIA IL
61615-7483
US

IV. Provider business mailing address

112 NE MADISON AVE
PEORIA IL
61602-1109
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-9189
  • Fax:
Mailing address:
  • Phone: 309-674-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070023184
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: