Healthcare Provider Details

I. General information

NPI: 1346375177
Provider Name (Legal Business Name): JEFFREY JAMESON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W EVERGREEN AVE STE 404
CHICAGO IL
60642-7113
US

IV. Provider business mailing address

4651 N GREENVIEW AVE APT 410
CHICAGO IL
60640-7944
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 312-860-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC009084
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number116050
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056010804
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: