Provider Demographics
NPI:1255431912
Name:MACZULSKI, JO ANNE (OTR L)
Entity type:Individual
Prefix:MS
First Name:JO
Middle Name:ANNE
Last Name:MACZULSKI
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 1:537 W ROSCOE ST
Mailing Address - Street 2:2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3518
Mailing Address - Country:US
Mailing Address - Phone:773-750-7497
Mailing Address - Fax:773-281-6020
Practice Address - Street 1:537 W ROSCOE ST
Practice Address - Street 2:2N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3518
Practice Address - Country:US
Practice Address - Phone:773-750-7497
Practice Address - Fax:773-281-6020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056000358225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633586OtherBC/BS PIN