Healthcare Provider Details

I. General information

NPI: 1669149407
Provider Name (Legal Business Name): JAMIE MARIE MALLEK MSOT OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2021
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 BORMET DR
MOKENA IL
60448-8303
US

IV. Provider business mailing address

13050 MEADOWLARK CT
HOMER GLEN IL
60491-9055
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone: 708-351-6264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.014334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: