Basic Information
| Provider Information | |||||||||
| NPI: | 1386207637 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NYSTROM | ||||||||
| FirstName: | JAIME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21863 BLUE BIRD LN | ||||||||
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| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604232292 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14711 S RAVINIA AVE | ||||||||
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| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604623100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082269200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 04/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.