Provider Demographics
NPI:1245347095
Name:BLEVINS, JENNIFER A
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:830 S ADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2877
Mailing Address - Country:US
Mailing Address - Phone:630-620-4433
Mailing Address - Fax:630-620-1148
Practice Address - Street 1:830 S ADDISON AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2877
Practice Address - Country:US
Practice Address - Phone:630-620-4433
Practice Address - Fax:630-620-1148
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-005403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21679Medicare ID - Type Unspecified