1457747685 NPI number — JESSICA ELLINGER OTR/L CBIS

Table of content: JESSICA ELLINGER OTR/L CBIS (NPI 1457747685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457747685 NPI number — JESSICA ELLINGER OTR/L CBIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLINGER
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L CBIS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLUEGEMAN
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L, CBIS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457747685
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3181 SANDHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48854-9425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-336-6060
Provider Business Mailing Address Fax Number:
517-336-6050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3181 SANDHILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48854-9425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-336-6060
Provider Business Practice Location Address Fax Number:
517-336-6050
Provider Enumeration Date:
04/14/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XN1300X , with the licence number:  5201008424 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5201008424 . This is a "OCCUPATIONAL THERAPIST LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 305197 . This is a "NATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY" identifier . This identifiers is of the category "OTHER".