Healthcare Provider Details

I. General information

NPI: 1790393650
Provider Name (Legal Business Name): JERRY MARK OTOOLE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24402 W LOCKPORT ST STE 215
PLAINFIELD IL
60544-4204
US

IV. Provider business mailing address

12816 TIMBER WOOD CIR
PLAINFIELD IL
60585-2974
US

V. Phone/Fax

Practice location:
  • Phone: 630-621-5824
  • Fax:
Mailing address:
  • Phone: 240-449-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071006413
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: