Provider Demographics
NPI:1558489526
Name:WILSON, JAN (ROT)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ROT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 LONGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-8304
Mailing Address - Country:US
Mailing Address - Phone:309-527-6240
Mailing Address - Fax:
Practice Address - Street 1:555 E CLAY ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:IL
Practice Address - Zip Code:61738-1508
Practice Address - Country:US
Practice Address - Phone:309-527-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist