Provider Demographics
NPI:1295703940
Name:JOHN, JESSICA N (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:JOHN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 S CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3113
Mailing Address - Country:US
Mailing Address - Phone:702-419-4142
Mailing Address - Fax:
Practice Address - Street 1:5530 S ELLIS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1402
Practice Address - Country:US
Practice Address - Phone:773-702-5573
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer