=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922652817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA MENDENHALL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2019
-----------------------------------------------------
Last Update Date | 10/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 STATE ST
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62439-1899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-943-7225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12510 SPRING HILL RD
-----------------------------------------------------
City | SUMNER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62466-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-553-4311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 05010632A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070026469
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------