Provider Demographics
NPI:1174642136
Name:PETERSON, JESSE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 N HERMITAGE AVE # 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2715
Mailing Address - Country:US
Mailing Address - Phone:773-575-6563
Mailing Address - Fax:
Practice Address - Street 1:222 S RIVERSIDE PLZ STE 830
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-5900
Practice Address - Country:US
Practice Address - Phone:866-386-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant