Provider Demographics
NPI:1497875934
Name:HUSTON, JERRY (PTA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:HUSTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21655 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-9519
Mailing Address - Country:US
Mailing Address - Phone:815-744-6813
Mailing Address - Fax:815-741-9577
Practice Address - Street 1:26555 S JACOB DR
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-5493
Practice Address - Country:US
Practice Address - Phone:815-483-8944
Practice Address - Fax:815-521-2896
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant