Healthcare Provider Details

I. General information

NPI: 1922486265
Provider Name (Legal Business Name): PHOEBE JEROUSEK OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 WESLEY AVE
EVANSTON IL
60202-1131
US

IV. Provider business mailing address

1204 WESLEY AVE
EVANSTON IL
60202-1131
US

V. Phone/Fax

Practice location:
  • Phone: 773-595-5640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number056010277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: