Provider Demographics
NPI:1134684798
Name:GRUNDEN, JESSICA ALYSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALYSE
Last Name:GRUNDEN
Suffix:
Gender:F
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 1:2474 N FLORIAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3083
Mailing Address - Country:US
Mailing Address - Phone:217-520-9099
Mailing Address - Fax:
Practice Address - Street 1:875 W MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3287
Practice Address - Country:US
Practice Address - Phone:217-872-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012037225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist