Provider Demographics
NPI:1861721540
Name:MCCOWAN, JESSICA RENEE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:MCCOWAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:811 N 1ST ST.
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-0095
Mailing Address - Country:US
Mailing Address - Phone:618-658-8144
Mailing Address - Fax:618-658-9146
Practice Address - Street 1:811 N 1ST ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1544
Practice Address - Country:US
Practice Address - Phone:618-658-8144
Practice Address - Fax:618-658-9146
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL048930OtherHEALTH ALLIANCE
IL4423522OtherBCBS
IL431187OtherHEALTHLINK
IL$$$$$$$$$001Medicaid
IL431187OtherHEALTHLINK