Provider Demographics
NPI:1730660887
Name:BLOUGH, JAMIE LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:BLOUGH
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 1:419 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3065
Mailing Address - Country:US
Mailing Address - Phone:815-715-0026
Mailing Address - Fax:
Practice Address - Street 1:600 N COMMONS DR STE 102
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4155
Practice Address - Country:US
Practice Address - Phone:708-478-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005001224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant