Healthcare Provider Details

I. General information

NPI: 1053596635
Provider Name (Legal Business Name): JODI HOFSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16639 HOLLAND AVE
SOUTH HOLLAND IL
60473-2845
US

IV. Provider business mailing address

16639 HOLLAND AVE
SOUTH HOLLAND IL
60473-2845
US

V. Phone/Fax

Practice location:
  • Phone: 708-705-4943
  • Fax: 708-596-8540
Mailing address:
  • Phone: 708-705-4943
  • Fax: 708-596-8540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberJH18760402A
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: