Provider Demographics
NPI:1346326923
Name:SWAN, JESSICA (OTRL)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SWAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4156 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520
Mailing Address - Country:US
Mailing Address - Phone:608-862-1750
Mailing Address - Fax:608-862-1750
Practice Address - Street 1:1763 S DIRCK DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6707
Practice Address - Country:US
Practice Address - Phone:815-233-5100
Practice Address - Fax:815-235-2233
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist