Provider Demographics
NPI:1548754591
Name:DRISCOLL, JESSICA LEE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:WINDSOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:209 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2235
Mailing Address - Country:US
Mailing Address - Phone:779-696-4590
Mailing Address - Fax:
Practice Address - Street 1:209 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2235
Practice Address - Country:US
Practice Address - Phone:779-696-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004386208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation