Provider Demographics
NPI:1982340832
Name:BULUSAN, JEWEL LEA MARIE UMUSO
Entity Type:Individual
Prefix:
First Name:JEWEL LEA MARIE
Middle Name:UMUSO
Last Name:BULUSAN
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 1:2110 S GOEBBERT RD APT 102
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-4260
Mailing Address - Country:US
Mailing Address - Phone:224-809-0342
Mailing Address - Fax:
Practice Address - Street 1:2110 S GOEBBERT RD APT 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-4260
Practice Address - Country:US
Practice Address - Phone:224-809-0342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014184225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist