Provider Demographics
NPI:1700295961
Name:BRUNETTI, JIM
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:BRUNETTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 S QUENTIN RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-6778
Mailing Address - Country:US
Mailing Address - Phone:847-485-3073
Mailing Address - Fax:
Practice Address - Street 1:2 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4341
Practice Address - Country:US
Practice Address - Phone:847-742-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010988101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1700295961Medicaid