Provider Demographics
NPI:1548596471
Name:LIGHTFOOT, JESSICA L (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:217-528-8962
Practice Address - Street 1:3020 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5915
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-789-2569
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208260044OtherMEDICARE PTAN