Provider Demographics
NPI:1063625820
Name:ROGGENBUCK, JACQUELYN MARIE (OTR)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:ROGGENBUCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:MARIE
Other - Last Name:PARTIPILO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:PO BOX 735263
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 ROXBURY ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7498
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-011026225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41046100Medicaid
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid