Provider Demographics
NPI:1982039350
Name:TRIMBLE, JENNIFER F (DT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:F
Last Name:TRIMBLE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:FASOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32 ETHELL PKWY
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4017
Mailing Address - Country:US
Mailing Address - Phone:309-454-2494
Mailing Address - Fax:
Practice Address - Street 1:32 ETHELL PKWY
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-4017
Practice Address - Country:US
Practice Address - Phone:309-454-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist