Provider Demographics
NPI:1679514350
Name:HULTMAN, JERILYNN LEA (OT)
Entity Type:Individual
Prefix:
First Name:JERILYNN
Middle Name:LEA
Last Name:HULTMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:951 ESSINGTON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8427
Practice Address - Country:US
Practice Address - Phone:815-942-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-003243225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056003243OtherLICENSE
IL216860066Medicare PIN
IL056003243OtherLICENSE