Provider Demographics
NPI:1598427080
Name:KENTGEN, JAMIE JENELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:JENELLE
Last Name:KENTGEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 RIVERDALE CT
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6821
Mailing Address - Country:US
Mailing Address - Phone:847-691-1845
Mailing Address - Fax:
Practice Address - Street 1:3815 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2488
Practice Address - Country:US
Practice Address - Phone:630-584-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014522225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056.014522OtherSTATE LICENSE