Provider Demographics
NPI:1629353685
Name:GOCOLAY, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:GOCOLAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 S 86TH AVE
Mailing Address - Street 2:406
Mailing Address - City:JUSTICE
Mailing Address - State:IL
Mailing Address - Zip Code:60458-1857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5625 W 79TH ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1349
Practice Address - Country:US
Practice Address - Phone:708-576-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist