Provider Demographics
NPI:1508028085
Name:LOVE, JESSICA RAE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:RAE
Last Name:LOVE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 EAST NINTH STREE
Mailing Address - Street 2:APT A
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-3454
Mailing Address - Country:US
Mailing Address - Phone:815-499-1269
Mailing Address - Fax:
Practice Address - Street 1:208 E 9TH ST
Practice Address - Street 2:APT A
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-2444
Practice Address - Country:US
Practice Address - Phone:815-499-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1484895172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker