Basic Information
Provider Information
NPI: 1003149725
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LANGILLE
FirstName: JESSE
MiddleName: FOREST
NamePrefix:  
NameSuffix:  
Credential: OT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 205 W WACKER DR
Address2: SUITE 1020
City: CHICAGO
State: IL
PostalCode: 606061216
CountryCode: US
TelephoneNumber: 3126400329
FaxNumber:  
Practice Location
Address1: 1509 S MICHIGAN AVE
Address2:  
City: CHICAGO
State: IL
PostalCode: 606052802
CountryCode: US
TelephoneNumber: 3124310434
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/14/2009
LastUpdateDate: 04/09/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X056008865ILY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 
225XH1200X  N Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand

No ID Information.


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