Provider Demographics
NPI:1144809344
Name:CLOUGH, JENNIFER JOAN (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOAN
Last Name:CLOUGH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 CHAMPAIGN AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-2451
Mailing Address - Country:US
Mailing Address - Phone:217-278-9817
Mailing Address - Fax:
Practice Address - Street 1:1000 PALM AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-6031
Practice Address - Country:US
Practice Address - Phone:217-278-9817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002633224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1075202OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY
IL057.002633OtherILLINOIS DEPARTMENT OF REGULATION