MEDICARE: JORDAN ALEECE GEHRIG COTA

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	224Z00000X	Occupational Therapy Assistant	057006017	IL

General Provider Information

NPI Number	:	1609560952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN ALEECE GEHRIG COTA

Provider Business Mailing Address
First Line	:	1497 N TOWN AVE
Second Line	:
City	:	PRINCEVILLE
State	:	IL
Zip	:	61559-9782
Country	:	US
Telephone Number	:	309-863-0601
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 S I ST
Second Line	:
City	:	MONMOUTH
State	:	IL
Zip	:	61462-1544
Country	:	US
Telephone Number	:	309-734-3811
Fax Number	:

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

Provider Enumeration Date	:	06/07/2023
Last Update Date	:	08/06/2023

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Directions to “ JORDAN ALEECE GEHRIG COTA” Practice Location

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