MEDICARE: MRS. JESSICA ANN PAULOSE OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056002560	IL

General Provider Information

NPI Number	:	1902911712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA ANN PAULOSE OTR

Provider Business Mailing Address
First Line	:	3703 W LAKE AVE
Second Line	:	SUITE 200
City	:	GLENVIEW
State	:	IL
Zip	:	60026-5823
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3703 W LAKE AVE
Second Line	:	SUITE 200
City	:	GLENVIEW
State	:	IL
Zip	:	60026-5823
Country	:	US
Telephone Number	:	847-998-1188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	05/06/2011

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