Provider Demographics
NPI:1497044861
Name:GAMBILL, JERED STEVEN (MSOTR/L)
Entity Type:Individual
Prefix:MR
First Name:JERED
Middle Name:STEVEN
Last Name:GAMBILL
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 E IL HIGHWAY 15
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-5072
Mailing Address - Country:US
Mailing Address - Phone:618-241-7039
Mailing Address - Fax:618-241-7039
Practice Address - Street 1:108 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-3624
Practice Address - Country:US
Practice Address - Phone:618-244-1302
Practice Address - Fax:618-244-1302
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist