Healthcare Provider Details

I. General information

NPI: 1700778610
Provider Name (Legal Business Name): JILLIAN VLASAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 S 48TH ST
TACOMA WA
98409-1919
US

IV. Provider business mailing address

407 MORGAN LN
FOX RIVER GROVE IL
60021-1253
US

V. Phone/Fax

Practice location:
  • Phone: 253-475-4611
  • Fax:
Mailing address:
  • Phone: 847-997-1082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.OT.70113872
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.016149
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: