Provider Demographics
NPI:1457821233
Name:GAITHER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GAITHER
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 1:2780 SANDHUTTON AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-7542
Mailing Address - Country:US
Mailing Address - Phone:618-246-0323
Mailing Address - Fax:
Practice Address - Street 1:1200 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECATONICA
Practice Address - State:IL
Practice Address - Zip Code:61063-9440
Practice Address - Country:US
Practice Address - Phone:815-239-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960047492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer