Provider Demographics
NPI:1588169825
Name:FREDERICK, JESSICA (COTA/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S. 270 4TH ST.
Mailing Address - Street 2:
Mailing Address - City:EOLA
Mailing Address - State:IL
Mailing Address - Zip Code:60519
Mailing Address - Country:US
Mailing Address - Phone:630-205-7415
Mailing Address - Fax:
Practice Address - Street 1:600 N COMMONS DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4154
Practice Address - Country:US
Practice Address - Phone:708-478-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004301224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant