Provider Demographics
NPI:1942524947
Name:EHLIN, JENNIFER M (MED , COTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:EHLIN
Suffix:
Gender:F
Credentials:MED , COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9426 OLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9562
Mailing Address - Country:US
Mailing Address - Phone:219-365-5878
Mailing Address - Fax:
Practice Address - Street 1:9426 OLCOTT AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9562
Practice Address - Country:US
Practice Address - Phone:219-365-5878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057000488224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant