Healthcare Provider Details

I. General information

NPI: 1598044851
Provider Name (Legal Business Name): JERRY BRASEL OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 W LINCOLN HWY (US ROUTE 30)
SCHERERVILLE IN
46375-1020
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 219-865-1436
  • Fax:
Mailing address:
  • Phone: 630-575-1916
  • Fax: 630-928-5016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31001355A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056-002245
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: