Provider Demographics
NPI:1376123570
Name:PARKS, JODIE (OTR)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13877 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-1210
Mailing Address - Country:US
Mailing Address - Phone:312-768-0694
Mailing Address - Fax:
Practice Address - Street 1:2600 COMPASS RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8001
Practice Address - Country:US
Practice Address - Phone:877-787-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011271225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty