Provider Demographics
NPI:1235375023
Name:WESTENHAVER, JESSICA M (PTA)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:M
Last Name:WESTENHAVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 EDGAR AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5249
Mailing Address - Country:US
Mailing Address - Phone:217-294-1706
Mailing Address - Fax:
Practice Address - Street 1:1613 EDGAR AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5249
Practice Address - Country:US
Practice Address - Phone:217-294-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-28
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003771A225200000X
IL227007327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant