Provider Demographics
NPI:1417249798
Name:CARROLL, JODI LEE (MS OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:LEE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 N WOLCOTT AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1640 N WELLS ST
Practice Address - Street 2:# 103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6087
Practice Address - Country:US
Practice Address - Phone:231-392-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist