Healthcare Provider Details

I. General information

NPI: 1487575114
Provider Name (Legal Business Name): CHRISTIEN MARIA JACOB OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 N CONVENT ST
BOURBONNAIS IL
60914-1300
US

IV. Provider business mailing address

17339 VALLEY FORGE DR
TINLEY PARK IL
60477-4507
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-9497
  • Fax:
Mailing address:
  • Phone: 708-942-9072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.012125
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: