Provider Demographics
NPI:1457476285
Name:JENSEN, JACQUELINE (OTR L)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:JENSEN
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 1:500 W SUPERIOR ST
Mailing Address - Street 2:#2204
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8132
Mailing Address - Country:US
Mailing Address - Phone:773-738-6365
Mailing Address - Fax:
Practice Address - Street 1:500 W SUPERIOR ST
Practice Address - Street 2:#2204
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-8132
Practice Address - Country:US
Practice Address - Phone:773-738-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56007801225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617235OtherBLUE CROSS BLUE SHIELD