Provider Demographics
NPI:1104034396
Name:SUPNEKAR, JYOTSNA R (OTR, CHT)
Entity Type:Individual
Prefix:
First Name:JYOTSNA
Middle Name:R
Last Name:SUPNEKAR
Suffix:
Gender:F
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:3465 BOX HILL CORPORATE CENTER DR
Practice Address - Street 2:SUITE G
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1261
Practice Address - Country:US
Practice Address - Phone:410-569-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00154000225X00000X, 225XH1200X
MD06635225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand