Provider Demographics
NPI:1619687456
Name:COMSTOCK, JESSICA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COMSTOCK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 E 750 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:CISSNA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60924-8778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 WARRINGTON AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5446
Practice Address - Country:US
Practice Address - Phone:217-649-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003879224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNONEMedicaid