Healthcare Provider Details

I. General information

NPI: 1063299527
Provider Name (Legal Business Name): JACOB DANIEL PEREZ MSAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 S GLADSTONE AVE
AURORA IL
60506-4877
US

IV. Provider business mailing address

24063 S BURR RD
CHANNAHON IL
60410-5205
US

V. Phone/Fax

Practice location:
  • Phone: 630-892-6431
  • Fax:
Mailing address:
  • Phone: 815-545-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: