Healthcare Provider Details

I. General information

NPI: 1194234385
Provider Name (Legal Business Name): JENNIFER ELIZABETH LONG OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 S NAPER BLVD STE 104
NAPERVILLE IL
60540-8398
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 630-369-2340
  • Fax: 630-369-2859
Mailing address:
  • Phone: 866-370-8206
  • Fax: 517-435-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number056003249
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: