MEDICARE: JENNIFER COULSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056010149	IL

General Provider Information

NPI Number	:	1720559388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER COULSON OTR/L

Provider Business Mailing Address
First Line	:	620 W ADDISON ST APT 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1702
Country	:	US
Telephone Number	:	773-973-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2018
Last Update Date	:	12/07/2018

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