Provider Demographics
NPI:1740247394
Name:DEBORD, JON A (PT MS ATC SCS)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:A
Last Name:DEBORD
Suffix:
Gender:M
Credentials:PT MS ATC SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-1330
Mailing Address - Country:US
Mailing Address - Phone:309-852-2200
Mailing Address - Fax:309-852-2402
Practice Address - Street 1:110 E 10TH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-1330
Practice Address - Country:US
Practice Address - Phone:309-852-2200
Practice Address - Fax:309-852-2402
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009875225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid
IL5272470002Medicare NSC