Provider Demographics
NPI:1770824237
Name:GIPSON, JODIE MARIE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:JODIE
Middle Name:MARIE
Last Name:GIPSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 N BOSWORTH AVE
Mailing Address - Street 2:UNIT 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2393
Mailing Address - Country:US
Mailing Address - Phone:573-837-2289
Mailing Address - Fax:
Practice Address - Street 1:1346 N BOSWORTH AVE
Practice Address - Street 2:UNIT 3
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2393
Practice Address - Country:US
Practice Address - Phone:573-837-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009860225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist