Provider Demographics
NPI:1376012518
Name:FLANAGAN, JILL DIANE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DIANE
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14110 S SHOSHONI DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8908
Mailing Address - Country:US
Mailing Address - Phone:708-334-6739
Mailing Address - Fax:
Practice Address - Street 1:14110 S SHOSHONI DR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8908
Practice Address - Country:US
Practice Address - Phone:783-334-6739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008584225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherSOCIAL SECURITY