Provider Demographics
NPI:1194331967
Name:EVANS, JENNIFER REBECCA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:REBECCA
Last Name:EVANS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1317 SIMMONS RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-6607
Mailing Address - Country:US
Mailing Address - Phone:618-401-9631
Mailing Address - Fax:
Practice Address - Street 1:623 HAMACHER ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1786
Practice Address - Country:US
Practice Address - Phone:618-939-0400
Practice Address - Fax:618-939-0253
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006313225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist