Basic Information
| Provider Information | |||||||||
| NPI: | 1649534181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622861048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184432177 | ||||||||
| FaxNumber: | 6184434731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622861048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184432177 | ||||||||
| FaxNumber: | 6184434731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 056003716 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.