Healthcare Provider Details

I. General information

NPI: 1750114351
Provider Name (Legal Business Name): JASMINE A JACOB OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4668 PEMBROKE BLVD STE 115B
VIRGINIA BEACH VA
23455-6423
US

IV. Provider business mailing address

140 E LOOP RD
WHEATON IL
60189-8407
US

V. Phone/Fax

Practice location:
  • Phone: 757-648-8562
  • Fax:
Mailing address:
  • Phone: 312-243-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056016184
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119011387
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: