Provider Demographics
NPI:1902460405
Name:D'ADAM, JEFFREY JOHN (PTA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:D'ADAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16622 W 159TH ST STE 503
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8015
Mailing Address - Country:US
Mailing Address - Phone:815-838-5070
Mailing Address - Fax:815-838-5071
Practice Address - Street 1:16622 W 159TH ST STE 503
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8015
Practice Address - Country:US
Practice Address - Phone:815-838-5070
Practice Address - Fax:815-838-5071
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008543225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant