Healthcare Provider Details

I. General information

NPI: 1386005890
Provider Name (Legal Business Name): JESSICA LANE HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 W CARROLL AVE
CHICAGO IL
60607-1105
US

IV. Provider business mailing address

2747 WOODWORTH PL
HAZEL CREST IL
60429-1775
US

V. Phone/Fax

Practice location:
  • Phone: 312-733-0883
  • Fax:
Mailing address:
  • Phone: 480-244-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: