Provider Demographics
NPI:1467189407
Name:ESPEJO, JHERUM BARDOQUILLO (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JHERUM
Middle Name:BARDOQUILLO
Last Name:ESPEJO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W GRANT AVER
Mailing Address - Street 2:APT 4
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920
Mailing Address - Country:US
Mailing Address - Phone:224-266-7388
Mailing Address - Fax:
Practice Address - Street 1:535 W GRANT AVE APT 4
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-3276
Practice Address - Country:US
Practice Address - Phone:224-266-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070026385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist