Healthcare Provider Details

I. General information

NPI: 1417845728
Provider Name (Legal Business Name): MICHAEL JAMIESON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 LATHROP AVE
RIVER FOREST IL
60305-2122
US

IV. Provider business mailing address

1750 N MOHAWK ST APT 305
CHICAGO IL
60614-4855
US

V. Phone/Fax

Practice location:
  • Phone: 708-366-6411
  • Fax:
Mailing address:
  • Phone: 574-340-6190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: