Provider Demographics
NPI:1588951222
Name:JEZIORNY KEROUAC, LISA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:JEZIORNY KEROUAC
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 LARRY POWER RD STE A
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5190
Mailing Address - Country:US
Mailing Address - Phone:815-216-4600
Mailing Address - Fax:815-216-4626
Practice Address - Street 1:372 LARRY POWER RD STE A
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5190
Practice Address - Country:US
Practice Address - Phone:815-216-4600
Practice Address - Fax:815-216-4626
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist