Healthcare Provider Details

I. General information

NPI: 1356854921
Provider Name (Legal Business Name): JENNIFER R GILL MSOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10940 E US HIGHWAY 36
AVON IN
46123-7980
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 317-808-7000
  • Fax:
Mailing address:
  • Phone: 630-575-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31005305A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: