Provider Demographics
NPI:1003027244
Name:GOMES, JACQUELINE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:GOMES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-2451
Mailing Address - Country:US
Mailing Address - Phone:618-542-3386
Mailing Address - Fax:618-542-3386
Practice Address - Street 1:755 N LAKE DR
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-2451
Practice Address - Country:US
Practice Address - Phone:618-542-3386
Practice Address - Fax:618-542-3386
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-008468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist