Provider Demographics
NPI:1992360739
Name:KUDIA, JESSICA LOUISE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:KUDIA
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 1:16230 S HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-2345
Mailing Address - Country:US
Mailing Address - Phone:815-210-2501
Mailing Address - Fax:
Practice Address - Street 1:1715 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-2751
Practice Address - Country:US
Practice Address - Phone:815-991-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008551225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant