Healthcare Provider Details

I. General information

NPI: 1467919910
Provider Name (Legal Business Name): JESSICA NICOLE KISTLER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA NICOLE BAKER

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 W POLK AVE
CHARLESTON IL
61920-2557
US

IV. Provider business mailing address

102 W PINE DR
EFFINGHAM IL
62401-2954
US

V. Phone/Fax

Practice location:
  • Phone: 618-231-1877
  • Fax:
Mailing address:
  • Phone: 618-231-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.012923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: