Healthcare Provider Details

I. General information

NPI: 1003149725
Provider Name (Legal Business Name): JESSE FOREST LANGILLE OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 S MICHIGAN AVE
CHICAGO IL
60605-2802
US

IV. Provider business mailing address

205 W WACKER DR SUITE 1020
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 312-431-0434
  • Fax:
Mailing address:
  • Phone: 312-640-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT21410
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056008865
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: