Provider Demographics
NPI:1952969453
Name:JOLIET CLINIC
Entity Type:Organization
Organization Name:JOLIET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOHSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRADC
Authorized Official - Phone:815-630-2164
Mailing Address - Street 1:807 W JEFFERSON ST UNIT P
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-7301
Mailing Address - Country:US
Mailing Address - Phone:815-630-2164
Mailing Address - Fax:
Practice Address - Street 1:807 W JEFFERSON ST UNIT P
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-7301
Practice Address - Country:US
Practice Address - Phone:815-630-2164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health