Basic Information
| Provider Information | |||||||||
| NPI: | 1932639788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALILI | ||||||||
| FirstName: | JASMINE | ||||||||
| MiddleName: | DOMINIQUE | ||||||||
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| Credential: | PA, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4108 NAUTILUS CT APT A | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600881155 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3333 GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600643037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475783000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2255A2300X | 2601001358 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 2000017753 | 01 | BOARD OF CERTIFICATION | OTHER | 2601001358 | 01 | MI | MI DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS | OTHER |