Healthcare Provider Details

I. General information

NPI: 1225777824
Provider Name (Legal Business Name): JOVANA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5719 W FULLERTON AVE APT 1F
CHICAGO IL
60639-2337
US

IV. Provider business mailing address

3453 N KOSTNER AVE
CHICAGO IL
60641-3806
US

V. Phone/Fax

Practice location:
  • Phone: 773-865-2384
  • Fax:
Mailing address:
  • Phone: 872-800-7164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: