Basic Information
| Provider Information | |||||||||
| NPI: | 1841859873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | JORDYN | ||||||||
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| Credential: | OTD, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 REVERE DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600628005 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 738 W ARMY TRAIL RD | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154691500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2019 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 225X00000X | 056.015144 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.