Provider Demographics
NPI:1780001644
Name:GREGORY, JESSICA RENAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENAE
Last Name:GREGORY
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 1:21 OAK PARK DR W
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5706
Mailing Address - Country:US
Mailing Address - Phone:618-780-5372
Mailing Address - Fax:
Practice Address - Street 1:900 S RAND RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2450
Practice Address - Country:US
Practice Address - Phone:847-726-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003437224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant