Provider Demographics
NPI:1467978882
Name:CREDILLE, JAMIESON T (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIESON
Middle Name:T
Last Name:CREDILLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1952 ABERDEEN CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3175
Mailing Address - Country:US
Mailing Address - Phone:815-991-2333
Mailing Address - Fax:815-748-3014
Practice Address - Street 1:1513 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-2703
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-991-9484
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070023046OtherPHYSICAL THERAPIST LICENSE