Provider Demographics
NPI:1265816383
Name:KAHOUSH, JERIES NICOLA (LMT)
Entity Type:Individual
Prefix:
First Name:JERIES
Middle Name:NICOLA
Last Name:KAHOUSH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12834 S APPLE LN
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-2735
Mailing Address - Country:US
Mailing Address - Phone:773-531-5269
Mailing Address - Fax:
Practice Address - Street 1:939 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2638
Practice Address - Country:US
Practice Address - Phone:312-548-0601
Practice Address - Fax:312-277-7475
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.018078171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor