Provider Demographics
NPI:1417366451
Name:BLISS, JENNIFER (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLISS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:201 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAYBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:61770-9497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAYBROOK
Practice Address - State:IL
Practice Address - Zip Code:61770-9497
Practice Address - Country:US
Practice Address - Phone:217-714-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003147224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant