Healthcare Provider Details

I. General information

NPI: 1386565695
Provider Name (Legal Business Name): LOGAN ALLEYSE JACOBS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 HAGEN RD
BRUSSELS IL
62013-4548
US

IV. Provider business mailing address

181 HAGEN RD
BRUSSELS IL
62013-4548
US

V. Phone/Fax

Practice location:
  • Phone: 217-730-6302
  • Fax:
Mailing address:
  • Phone: 217-730-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.026987
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: