Provider Demographics
NPI:1114640539
Name:GOSSELIN, JENNA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GOSSELIN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4157 N CLARENDON AVE APT 807
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5202
Mailing Address - Country:US
Mailing Address - Phone:603-657-5329
Mailing Address - Fax:
Practice Address - Street 1:3225 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-4823
Practice Address - Country:US
Practice Address - Phone:603-657-5329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960054042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer