Provider Demographics
NPI:1417259789
Name:VICKERY, JESSICA E (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:VICKERY
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 N SPRING AVE FRNT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5984
Mailing Address - Country:US
Mailing Address - Phone:630-750-2209
Mailing Address - Fax:
Practice Address - Street 1:2901 FINLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1041
Practice Address - Country:US
Practice Address - Phone:630-495-6800
Practice Address - Fax:630-495-8200
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009207225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist