Provider Demographics
NPI:1164856530
Name:MAHILO, JASON DAVID (MOTR/L)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:MAHILO
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N BROADWAY ST APT 402
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4854
Mailing Address - Country:US
Mailing Address - Phone:440-213-0106
Mailing Address - Fax:440-649-7446
Practice Address - Street 1:7250 ARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3766
Practice Address - Country:US
Practice Address - Phone:440-213-0106
Practice Address - Fax:440-649-7446
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.010065225X00000X
IN31005875A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist