Provider Demographics
NPI:1114385382
Name:PATTENGALE, JASON ALLAN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ALLAN
Last Name:PATTENGALE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WEST ST
Mailing Address - Street 2:APT E10
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182
Mailing Address - Country:US
Mailing Address - Phone:262-909-2185
Mailing Address - Fax:
Practice Address - Street 1:900 S RAND RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2450
Practice Address - Country:US
Practice Address - Phone:847-726-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.011334225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist