Basic Information
Provider Information | |||||||||
NPI: | 1881853372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SO | ||||||||
FirstName: | JAIME | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5005 NEWPORT DR | ||||||||
Address2: | SUITE 401 | ||||||||
City: | ROLLING MEADOWS | ||||||||
State: | IL | ||||||||
PostalCode: | 600083832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477971050 | ||||||||
FaxNumber: | 8477971337 | ||||||||
Practice Location | |||||||||
Address1: | 1625 SHERIDAN RD | ||||||||
Address2: | SUITE A | ||||||||
City: | WILMETTE | ||||||||
State: | IL | ||||||||
PostalCode: | 600911824 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8472562890 | ||||||||
FaxNumber: | 8472562802 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2008 | ||||||||
LastUpdateDate: | 06/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070015815 | IL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.