Provider Demographics
NPI:1316693526
Name:JARVIS, DIANE (OTR/L)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JARVIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7426 ASHTON VILLA
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2719
Mailing Address - Country:US
Mailing Address - Phone:815-501-2537
Mailing Address - Fax:
Practice Address - Street 1:2112 W GALENA BLVD STE 8-316
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3255
Practice Address - Country:US
Practice Address - Phone:630-661-7253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist