MEDICARE: JESSICA BRONSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	225100000X	Physical Therapist		IL

General Provider Information

NPI Number	:	1063827004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BRONSON

Provider Business Mailing Address
First Line	:	4828 N MELVINA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2906
Country	:	US
Telephone Number	:	314-517-6687
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 HIGHWAY AVE
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-1631
Country	:	US
Telephone Number	:	219-513-8311
Fax Number	:	708-479-2112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2014
Last Update Date	:	04/16/2024

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