Healthcare Provider Details

I. General information

NPI: 1851847313
Provider Name (Legal Business Name): JENNA RUHOLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MEDICAL PARK DR FL 1
EFFINGHAM IL
62401-2191
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4653
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-3003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2016030308
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: