Provider Demographics
NPI:1437484110
Name:LICUP, JEFFERSON JAMES MAHINAY (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON JAMES
Middle Name:MAHINAY
Last Name:LICUP
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 TIGER ST
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2053
Mailing Address - Country:US
Mailing Address - Phone:708-822-8886
Mailing Address - Fax:630-378-4839
Practice Address - Street 1:226 TIGER ST
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-2053
Practice Address - Country:US
Practice Address - Phone:708-822-8886
Practice Address - Fax:630-378-4839
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007185225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist