Provider Demographics
NPI:1174782445
Name:ANDERSON, JESSICA L
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:ROBBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:259 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2465
Mailing Address - Country:US
Mailing Address - Phone:309-338-0048
Mailing Address - Fax:
Practice Address - Street 1:259 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2465
Practice Address - Country:US
Practice Address - Phone:309-338-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist