=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588951222
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE JEZIORNY KEROUAC O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2011
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 372 LARRY POWER RD STE A
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-5190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-216-4600
-----------------------------------------------------
Fax | 815-216-4626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 372 LARRY POWER RD STE A
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-5190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-216-4600
-----------------------------------------------------
Fax | 815-216-4626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046010449
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------