Provider Demographics
NPI:1558434829
Name:DEDERICHS, JAYNE L (OTRL)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:L
Last Name:DEDERICHS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10618 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-2581
Mailing Address - Country:US
Mailing Address - Phone:708-923-0891
Mailing Address - Fax:
Practice Address - Street 1:17850 KEDZIE AVE
Practice Address - Street 2:SUITE 2300
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2058
Practice Address - Country:US
Practice Address - Phone:708-922-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL89772Medicare ID - Type Unspecified