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General NPI Number Information
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NPI Number | 1992360739
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Entity Type | Individual
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Provider Name | JESSICA LOUISE KUDIA PTA
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Gender | Female
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Dates
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Enumeration Date | 05/07/2019
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Last Update Date | 05/07/2019
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Provider Practice Location Address
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Address Line | 1715 DEKALB AVE
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City | SYCAMORE
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State | IL
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Zip | 60178-2751
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Country | US
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Telephone | 815-991-5760
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Fax |
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Provider Business Mailing Address
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Address Line | 16230 S HOWARD ST
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City | PLAINFIELD
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State | IL
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Zip | 60586-2345
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Country | US
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Telephone | 815-210-2501
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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 | 160.008551
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License Number State | IL
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