=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982256301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JALYN APRIL SALAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 07/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 704 S ILLINOIS ST
-----------------------------------------------------
City | GENESEO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-944-6424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4024 N LINWOOD AVE
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-343-4136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 057.003940
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------