Provider Demographics
NPI:1972872067
Name:STUCKMAN, JESSICA M (MOTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:STUCKMAN
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5128 HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9571
Mailing Address - Country:US
Mailing Address - Phone:217-257-2474
Mailing Address - Fax:
Practice Address - Street 1:301 CHICAGO AVE
Practice Address - Street 2:3NE
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2360
Practice Address - Country:US
Practice Address - Phone:217-257-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist