Provider Demographics
NPI:1265096945
Name:GONZALEZ, JACQUELINE N/A (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:N/A
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 S 56TH CT
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804
Mailing Address - Country:US
Mailing Address - Phone:708-714-7919
Mailing Address - Fax:
Practice Address - Street 1:3521 S 56TH CT
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804
Practice Address - Country:US
Practice Address - Phone:708-714-7919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007922225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant