Provider Demographics
NPI:1043802820
Name:EVANS, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 JONATHAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ARTHUR
Mailing Address - State:IL
Mailing Address - Zip Code:61911-6108
Mailing Address - Country:US
Mailing Address - Phone:217-962-0614
Mailing Address - Fax:
Practice Address - Street 1:2046 JONATHAN CREEK RD
Practice Address - Street 2:
Practice Address - City:ARTHUR
Practice Address - State:IL
Practice Address - Zip Code:61911-6108
Practice Address - Country:US
Practice Address - Phone:217-962-0614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227015675225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist