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General NPI Number Information
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NPI Number | 1174642136
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Entity Type | Individual
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Provider Name | JESSE PETERSON PHYSICAL THERAPIST
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Gender | Male
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 222 S RIVERSIDE PLZ STE 830
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City | CHICAGO
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State | IL
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Zip | 60606-5900
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Country | US
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Telephone | 866-386-0773
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Fax |
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Provider Business Mailing Address
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Address Line | 5015 N HERMITAGE AVE # 1
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City | CHICAGO
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State | IL
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Zip | 60640-2715
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Country | US
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Telephone | 773-575-6563
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State | IL
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