Healthcare Provider Details

I. General information

NPI: 1558275511
Provider Name (Legal Business Name): JAY REISS OTD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-6262
US

IV. Provider business mailing address

4121 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-6262
US

V. Phone/Fax

Practice location:
  • Phone: 618-214-4685
  • Fax:
Mailing address:
  • Phone: 618-214-4685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056027321
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: