Provider Demographics
NPI:1548429129
Name:DE JESUS, GEMMALYN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:GEMMALYN
Middle Name:
Last Name:DE JESUS
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 1:5840 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-1133
Mailing Address - Country:US
Mailing Address - Phone:630-810-1054
Mailing Address - Fax:
Practice Address - Street 1:6801 HIGH GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7585
Practice Address - Country:US
Practice Address - Phone:630-424-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003219225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant