Provider Demographics
NPI:1780321836
Name:JAGEMANN, NICOLE MEGHAN (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MEGHAN
Last Name:JAGEMANN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 W WAYMAN ST APT 602
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1700
Mailing Address - Country:US
Mailing Address - Phone:920-905-5072
Mailing Address - Fax:
Practice Address - Street 1:3800 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3606
Practice Address - Country:US
Practice Address - Phone:773-478-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014756225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist