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General NPI Number Information
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NPI Number | 1184193328
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Entity Type | Individual
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Provider Name | JAZMINE SHAYNIKA MACK OTR/L
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Gender | Female
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Dates
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Enumeration Date | 11/16/2018
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Last Update Date | 11/16/2018
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Provider Practice Location Address
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Address Line | 3633 BREAKERS DR
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1054
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Country | US
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Telephone | 708-747-3333
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Fax |
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Provider Business Mailing Address
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Address Line | 134 MASON ST
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City | CALUMET CITY
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State | IL
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Zip | 60409-5220
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Country | US
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Telephone | 708-351-3021
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 056.012705
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License Number State | IL
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