Provider Demographics
NPI:1427748730
Name:PORTER, JENNA (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1604
Mailing Address - Country:US
Mailing Address - Phone:815-431-5230
Mailing Address - Fax:
Practice Address - Street 1:1100 E NORRIS DR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1604
Practice Address - Country:US
Practice Address - Phone:815-431-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291476225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist