Basic Information
| Provider Information | |||||||||
| NPI: | 1851847313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUHOLL | ||||||||
| FirstName: | JENNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
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| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384653 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9515 HOLY CROSS LN STE 2 | ||||||||
| Address2: | |||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173473003 | ||||||||
| FaxNumber: | 2173473005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2016 | ||||||||
| LastUpdateDate: | 11/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 2016030308 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.