Provider Demographics
NPI:1790291474
Name:REYNOLDS, JENNIFER LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:REYNOLDS
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 1:111 W. MOUND STREET
Mailing Address - Street 2:
Mailing Address - City:STE. MARIE
Mailing Address - State:IL
Mailing Address - Zip Code:62459-0185
Mailing Address - Country:US
Mailing Address - Phone:618-455-3396
Mailing Address - Fax:
Practice Address - Street 1:500 W CLOVER ST
Practice Address - Street 2:
Practice Address - City:HUTSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62433-1017
Practice Address - Country:US
Practice Address - Phone:618-563-4812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006742225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist