Provider Demographics
NPI:1437853306
Name:THIELSEN, JESSE (MT-BC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:THIELSEN
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-2369
Mailing Address - Country:US
Mailing Address - Phone:815-271-1379
Mailing Address - Fax:
Practice Address - Street 1:490 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-2369
Practice Address - Country:US
Practice Address - Phone:815-271-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14756225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist