MEDICARE: JENNIFER POLLACK OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056009977	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	056009977	OTHER	IL	LICENSE

General Provider Information

NPI Number	:	1568707198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER POLLACK OTR/L

Provider Business Mailing Address
First Line	:	6708 N OXFORD AVE
Second Line	:	STE 2
City	:	CHICAGO
State	:	IL
Zip	:	60631-1327
Country	:	US
Telephone Number	:	773-459-2007
Fax Number	:

Provider Business Practice Location Address
First Line	:	6708 N OXFORD AVE
Second Line	:	STE 2
City	:	CHICAGO
State	:	IL
Zip	:	60631-1327
Country	:	US
Telephone Number	:	773-459-2007
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2012
Last Update Date	:	12/08/2012

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