Provider Demographics
NPI:1760952824
Name:IVARSON, KJERSTEN MAE (PT)
Entity Type:Individual
Prefix:
First Name:KJERSTEN
Middle Name:MAE
Last Name:IVARSON
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 1:1402 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-2345
Mailing Address - Country:US
Mailing Address - Phone:815-626-4238
Mailing Address - Fax:
Practice Address - Street 1:408 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-2904
Practice Address - Country:US
Practice Address - Phone:815-772-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.012753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist