Provider Demographics
NPI:1417166349
Name:KONECKI, JERI RUTH (COTA L)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:RUTH
Last Name:KONECKI
Suffix:
Gender:F
Credentials:COTA L
Other - Prefix:
Other - First Name:JERI
Other - Middle Name:RUTH
Other - Last Name:NORDGREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA L
Mailing Address - Street 1:1589 CONDOR DR
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-3599
Mailing Address - Country:US
Mailing Address - Phone:815-468-2079
Mailing Address - Fax:
Practice Address - Street 1:445 N WELLS ST
Practice Address - Street 2:SUITE 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-4579
Practice Address - Country:US
Practice Address - Phone:800-494-9936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant