Provider Demographics
NPI:1164018990
Name:BELBA, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BELBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 N 61ST ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62201-2503
Mailing Address - Country:US
Mailing Address - Phone:618-406-2017
Mailing Address - Fax:
Practice Address - Street 1:3354 JEROME LN
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2604
Practice Address - Country:US
Practice Address - Phone:618-337-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008972225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant