Provider Demographics
NPI:1134343916
Name:JUSTICE, JAMIE L (PT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:JUSTICE
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 1:371 QUINLAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-8240
Mailing Address - Country:US
Mailing Address - Phone:815-754-5339
Mailing Address - Fax:
Practice Address - Street 1:400 E HILLCREST DR STE 110
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2470
Practice Address - Country:US
Practice Address - Phone:815-758-5508
Practice Address - Fax:815-758-5537
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46251Medicare PIN