Healthcare Provider Details

I. General information

NPI: 1104603679
Provider Name (Legal Business Name): JESSICA KAY HUTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 BRADY MILL RD
ANNA IL
62906-2306
US

IV. Provider business mailing address

1401 N STATE ST
MARION IL
62959-2989
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-6343
  • Fax:
Mailing address:
  • Phone: 618-922-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.006031
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: