Provider Demographics
NPI:1073920658
Name:RIEDLE, JENNIFER MARIE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:RIEDLE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 1750TH AVE
Mailing Address - Street 2:
Mailing Address - City:MT. PULASKI
Mailing Address - State:IL
Mailing Address - Zip Code:62548
Mailing Address - Country:US
Mailing Address - Phone:217-871-5302
Mailing Address - Fax:
Practice Address - Street 1:412 1750TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PULASKI
Practice Address - State:IL
Practice Address - Zip Code:62548-6641
Practice Address - Country:US
Practice Address - Phone:217-871-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002570224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant