Provider Demographics
NPI:1326891052
Name:LORTS, JESSICA ANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:LORTS
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 1:1136 EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:IL
Mailing Address - Zip Code:62037-1289
Mailing Address - Country:US
Mailing Address - Phone:618-535-0469
Mailing Address - Fax:
Practice Address - Street 1:821 W HIGHWAY 50 STE 150
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1828
Practice Address - Country:US
Practice Address - Phone:618-726-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.015941225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist