Provider Demographics
NPI:1346828563
Name:JACOB LEDESMA LLC
Entity Type:Organization
Organization Name:JACOB LEDESMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:LEDESMA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:815-295-4320
Mailing Address - Street 1:588 WILLIAM R LATHAM SENIOR DRIVE
Mailing Address - Street 2:STE 5
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-937-0446
Mailing Address - Fax:
Practice Address - Street 1:588 WILLIAM R LATHAM SENIOR DRIVE
Practice Address - Street 2:STE 5
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-937-0446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy