Provider Demographics
NPI:1861654816
Name:BOSCH, JILL ELLEN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELLEN
Last Name:BOSCH
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 1:104 S HOPKINS ST
Mailing Address - Street 2:
Mailing Address - City:NEWMAN
Mailing Address - State:IL
Mailing Address - Zip Code:61942-9401
Mailing Address - Country:US
Mailing Address - Phone:217-837-2889
Mailing Address - Fax:
Practice Address - Street 1:400 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHRISMAN
Practice Address - State:IL
Practice Address - Zip Code:61924-1042
Practice Address - Country:US
Practice Address - Phone:217-269-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002460224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant