Provider Demographics
NPI:1922560069
Name:MORTILLARO, JESSICA A (ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:MORTILLARO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 OAKTON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2722
Mailing Address - Country:US
Mailing Address - Phone:847-721-1351
Mailing Address - Fax:
Practice Address - Street 1:7400 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1402
Practice Address - Country:US
Practice Address - Phone:708-209-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0042962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer