Basic Information
| Provider Information | |||||||||
| NPI: | 1104433457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | JESSIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 E FAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624013605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176638674 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2611 S BANKER ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172804550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2020 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.