Healthcare Provider Details

I. General information

NPI: 1609560952
Provider Name (Legal Business Name): JORDAN ALEECE GEHRIG COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 08/06/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S I ST
MONMOUTH IL
61462-1544
US

IV. Provider business mailing address

1497 N TOWN AVE
PRINCEVILLE IL
61559-9782
US

V. Phone/Fax

Practice location:
  • Phone: 309-734-3811
  • Fax:
Mailing address:
  • Phone: 309-863-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057006017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: