Provider Demographics
NPI:1083724751
Name:SHADDEN, JENNIFER (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHADDEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2609
Mailing Address - Country:US
Mailing Address - Phone:773-284-6735
Mailing Address - Fax:773-284-6820
Practice Address - Street 1:6255 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2609
Practice Address - Country:US
Practice Address - Phone:773-284-6735
Practice Address - Fax:773-284-6820
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 7865225X00000X
IL056.008744225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist