Healthcare Provider Details

I. General information

NPI: 1447155445
Provider Name (Legal Business Name): OLJ LEGACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19740 GOVERNORS HWY STE 100
FLOSSMOOR IL
60422-2085
US

IV. Provider business mailing address

19740 GOVERNORS HWY STE 100
FLOSSMOOR IL
60422-2085
US

V. Phone/Fax

Practice location:
  • Phone: 815-534-1367
  • Fax: 815-348-6101
Mailing address:
  • Phone: 815-534-1367
  • Fax: 815-348-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TYRONE JACKSON
Title or Position: PRESIDENT
Credential:
Phone: 202-360-1885