Provider Demographics
NPI:1720218852
Name:JENKINS, LAURA J (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 KEATON CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8220
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:636-422-1051
Practice Address - Street 1:5300 N ILLINOIS
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2700
Practice Address - Country:US
Practice Address - Phone:618-624-9300
Practice Address - Fax:618-307-3435
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001960225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150900025Medicare PIN
IL532400007Medicare PIN