Provider Demographics
NPI:1003372426
Name:GUZMAN, JESSICA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GUZMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:66 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7325
Mailing Address - Country:US
Mailing Address - Phone:312-705-6700
Mailing Address - Fax:
Practice Address - Street 1:3156 S KOMENSKY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4913
Practice Address - Country:US
Practice Address - Phone:773-698-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004993224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNAOtherNA