Provider Demographics
NPI:1245606821
Name:DAVIDSON, JENNIFER
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:DAVIDSON
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 1:218 E BENSON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1223
Mailing Address - Country:US
Mailing Address - Phone:217-491-2651
Mailing Address - Fax:
Practice Address - Street 1:114 N MONROE ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1427
Practice Address - Country:US
Practice Address - Phone:217-285-1915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.016668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist