Active NPI
Jefferson James Mahinay Licup, OTR/L
- Occupational Therapist
- Bolingbrook, IL
National Provider Identifier
1437484110
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapist
- License
- 056007185
- Practice address
- 226 Tiger St
Bolingbrook, IL 60490-2053 - Phone
- (708) 822-8886
- Fax
- (630) 378-4839
- NPI assigned
- Oct 13, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapist | 225X00000X | 056007185 | IL | Primary |
Addresses
Primary practice location
226 Tiger St
Bolingbrook, IL 60490-2053
Mailing address
226 Tiger St
Bolingbrook, IL 60490-2053
Phone (708) 822-8886
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 056007185 | IL | MD | Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1255392000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1255392000000",
"number": "1437484110",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "226 TIGER ST",
"city": "BOLINGBROOK",
"state": "IL",
"postal_code": "604902053",
"telephone_number": "708-822-8886",
"fax_number": "630-378-4839"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "226 TIGER ST",
"city": "BOLINGBROOK",
"state": "IL",
"postal_code": "604902053",
"telephone_number": "708-822-8886",
"fax_number": "630-378-4839"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LICUP",
"first_name": "JEFFERSON JAMES",
"middle_name": "MAHINAY",
"name_prefix": "Mr.",
"credential": "OTR/L",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-10-13",
"last_updated": "2009-10-13",
"status": "A"
},
"taxonomies": [
{
"code": "225X00000X",
"taxonomy_group": "",
"desc": "Occupational Therapist",
"state": "IL",
"license": "056007185",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bolingbrook, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.