Provider Demographics
NPI:1679649834
Name:FREDRICK, JENNIFER (COTA-L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FREDRICK
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 1:297 GREEN MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2568
Mailing Address - Country:US
Mailing Address - Phone:630-972-0036
Mailing Address - Fax:
Practice Address - Street 1:2901 FINLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1041
Practice Address - Country:US
Practice Address - Phone:630-495-6800
Practice Address - Fax:630-495-8200
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002411224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant