Provider Demographics
NPI:1376996157
Name:O'LEARY, JESSIE RAE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:RAE
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:RAE
Other - Last Name:MCKANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-647-2376
Practice Address - Street 1:1815 E IRELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-5790
Practice Address - Fax:574-647-5792
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32444225100000X
IN05012860A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT32444OtherPT LICENSE