Provider Demographics
NPI:1407962640
Name:BRICKER, JESSIE LYNNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LYNNE
Last Name:BRICKER
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 1:210 LAKE SHORE CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1422
Mailing Address - Country:US
Mailing Address - Phone:309-808-0278
Mailing Address - Fax:800-773-1682
Practice Address - Street 1:128 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2657
Practice Address - Country:US
Practice Address - Phone:800-773-1682
Practice Address - Fax:800-773-1682
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-006516225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100044415-62762-01Medicaid
IL08432058OtherBLUE CROSS BLUE SHIELD ID