Provider Demographics
NPI:1205076874
Name:DE LISLE, JEANNE T (PT)
Entity type:Individual
Prefix:MISS
First Name:JEANNE
Middle Name:T
Last Name:DE LISLE
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 1:718 N GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2508
Mailing Address - Country:US
Mailing Address - Phone:847-708-7680
Mailing Address - Fax:847-720-4335
Practice Address - Street 1:718 N GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2508
Practice Address - Country:US
Practice Address - Phone:847-708-7680
Practice Address - Fax:847-720-4335
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.005465174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist