Provider Demographics
NPI:1639598410
Name:HENRICHSEN, JILL (COTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:HENRICHSEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 SILVER LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013
Mailing Address - Country:US
Mailing Address - Phone:224-357-8398
Mailing Address - Fax:847-829-4487
Practice Address - Street 1:314 INVERNESS TRL
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5905
Practice Address - Country:US
Practice Address - Phone:815-363-7039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004000224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant