Provider Demographics
NPI:1346030251
Name:KATES, JAZ MCKENZIE (COTA)
Entity type:Individual
Prefix:
First Name:JAZ
Middle Name:MCKENZIE
Last Name:KATES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 N VETERANS PKWY STE 332
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-0917
Mailing Address - Country:US
Mailing Address - Phone:309-585-1809
Mailing Address - Fax:
Practice Address - Street 1:2103 N VETERANS PKWY STE 332
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0917
Practice Address - Country:US
Practice Address - Phone:309-585-1809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005634224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant