Provider Demographics
NPI:1861180283
Name:TREJO, JORGE MAURICIO (PTA)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:MAURICIO
Last Name:TREJO
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 1:221 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60112-4080
Mailing Address - Country:US
Mailing Address - Phone:815-981-2996
Mailing Address - Fax:
Practice Address - Street 1:599 PEARSON DR
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135-1383
Practice Address - Country:US
Practice Address - Phone:630-933-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009808225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant