Healthcare Provider Details

I. General information

NPI: 1396231676
Provider Name (Legal Business Name): SHRUTVA JANI OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W EVERGREEN AVE STE 404
CHICAGO IL
60642-7113
US

IV. Provider business mailing address

901 S ASHLAND AVE APT 1-1209
CHICAGO IL
60607-4001
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 630-776-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.012540
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: