Provider Demographics
NPI:1558419796
Name:STORTZ, JAMIE (MOTRL)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:STORTZ
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-6147
Mailing Address - Country:US
Mailing Address - Phone:847-204-0796
Mailing Address - Fax:
Practice Address - Street 1:33 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-6147
Practice Address - Country:US
Practice Address - Phone:847-204-0796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006330225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001636035Medicare UPIN
IL0007891758Medicare UPIN