Provider Demographics
NPI:1659679660
Name:GILLIAM, JASMINE JANE (OT)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:JANE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:
Other - Last Name:RANUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2211 N OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3351
Mailing Address - Country:US
Mailing Address - Phone:773-385-5875
Mailing Address - Fax:773-385-5851
Practice Address - Street 1:2211 N OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3351
Practice Address - Country:US
Practice Address - Phone:773-385-5875
Practice Address - Fax:773-385-5851
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007550225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics