MEDICARE: JACLYN TOVAR 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	225XP0019X	Physical Rehabilitation Occupational Therapist	056008245	IL

General Provider Information

NPI Number	:	1922312099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN TOVAR OTR/L

Provider Business Mailing Address
First Line	:	2548 W 107TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1133
Country	:	US
Telephone Number	:	773-253-2569
Fax Number	:

Provider Business Practice Location Address
First Line	:	2548 W 107TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1133
Country	:	US
Telephone Number	:	773-253-2569
Fax Number	:

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

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	08/02/2010

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