Healthcare Provider Details

I. General information

NPI: 1275180721
Provider Name (Legal Business Name): JAMIE LEE FAGERBURG MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S MICHIGAN AVE UNIT 1308
CHICAGO IL
60604-4203
US

IV. Provider business mailing address

1736 S UNION AVE
CHICAGO IL
60616-1153
US

V. Phone/Fax

Practice location:
  • Phone: 847-440-4305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.009870
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: