Provider Demographics
NPI:1255205662
Name:ANDERSON, JESSE L (DPT)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 W WOLFRAM ST APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5163
Mailing Address - Country:US
Mailing Address - Phone:859-640-8401
Mailing Address - Fax:
Practice Address - Street 1:711 W MAXWELL ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-5016
Practice Address - Country:US
Practice Address - Phone:312-355-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700249282251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic