Provider Demographics
NPI:1770765091
Name:KLOCKE, JENNIFER MARIE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:KLOCKE
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 1:8523 55TH ST
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9671
Mailing Address - Country:US
Mailing Address - Phone:309-799-5722
Mailing Address - Fax:
Practice Address - Street 1:8523 55TH ST
Practice Address - Street 2:
Practice Address - City:COAL VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61240-9671
Practice Address - Country:US
Practice Address - Phone:309-799-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist