1407962640 NPI number — MRS. JESSIE LYNNE BRICKER OTR/L

Table of content: MRS. JESSIE LYNNE BRICKER OTR/L (NPI 1407962640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407962640 NPI number — MRS. JESSIE LYNNE BRICKER OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRICKER
Provider First Name:
JESSIE
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407962640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 LAKE SHORE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61704-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-808-0278
Provider Business Mailing Address Fax Number:
800-773-1682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 WASHINGTON SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61571-2657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-773-1682
Provider Business Practice Location Address Fax Number:
800-773-1682
Provider Enumeration Date:
08/21/2006

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: 225XP0200X , with the licence number:  056-006516 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100044415-62762-01 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08432058 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com