Provider Demographics
NPI:1386674174
Name:MITRA, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MITRA
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 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1940
Mailing Address - Fax:630-928-5040
Practice Address - Street 1:440 E ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-3918
Practice Address - Country:US
Practice Address - Phone:630-293-5300
Practice Address - Fax:630-293-9800
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ26255Medicare UPIN
ILK11326Medicare ID - Type Unspecified