Provider Demographics
NPI:1528189859
Name:JESKE, TRACI M (DEVL THERAPIST)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:JESKE
Suffix:
Gender:F
Credentials:DEVL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHRISTOPHER WAY APT 6
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8509
Mailing Address - Country:US
Mailing Address - Phone:773-315-9465
Mailing Address - Fax:
Practice Address - Street 1:507 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3201
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist