Provider Demographics
NPI:1346253382
Name:PETERSON, JEANNE (DPT)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 N SOUTHPORT AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3223
Mailing Address - Country:US
Mailing Address - Phone:773-610-5252
Mailing Address - Fax:
Practice Address - Street 1:8833 GROSS POINT RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1859
Practice Address - Country:US
Practice Address - Phone:847-674-2630
Practice Address - Fax:847-674-4042
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist