Provider Demographics
NPI:1477869535
Name:REISS, JEAN MICHELLE (DT)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MICHELLE
Last Name:REISS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:608 STEARN DR
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:IL
Mailing Address - Zip Code:60135-1456
Mailing Address - Country:US
Mailing Address - Phone:847-712-2049
Mailing Address - Fax:
Practice Address - Street 1:608 STEARN DR
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135-1456
Practice Address - Country:US
Practice Address - Phone:847-712-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist