Provider Demographics
NPI:1700803558
Name:STINE, JENNIFER EILEEN (MPA, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:EILEEN
Last Name:STINE
Suffix:
Gender:F
Credentials:MPA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 S PIATT ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-2122
Mailing Address - Country:US
Mailing Address - Phone:217-762-4929
Mailing Address - Fax:217-762-4929
Practice Address - Street 1:133 S PIATT ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-2122
Practice Address - Country:US
Practice Address - Phone:217-762-4929
Practice Address - Fax:217-762-4929
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILJS30340801POtherE.I SPEC, OT