Provider Demographics
NPI:1457496267
Name:MERTH, JENNIFER (MT-BC, NMT, DT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MERTH
Suffix:
Gender:F
Credentials:MT-BC, NMT, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-0102
Mailing Address - Country:US
Mailing Address - Phone:815-875-5848
Mailing Address - Fax:815-875-5848
Practice Address - Street 1:816 S 1ST ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2404
Practice Address - Country:US
Practice Address - Phone:815-875-5848
Practice Address - Fax:815-875-5848
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01376225A00000X
ILJM53230998P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371343960OtherFEIN