Provider Demographics
NPI:1790500676
Name:COLE, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 HOLDEN CIR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4430
Mailing Address - Country:US
Mailing Address - Phone:708-261-7488
Mailing Address - Fax:
Practice Address - Street 1:4555 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2102
Practice Address - Country:US
Practice Address - Phone:773-328-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227023204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist