Healthcare Provider Details

I. General information

NPI: 1720962202
Provider Name (Legal Business Name): JESSICA ANN GUBALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W WELLINGTON AVE APT 2C
CHICAGO IL
60657-7401
US

IV. Provider business mailing address

607 W WELLINGTON AVE APT 2C
CHICAGO IL
60657-7401
US

V. Phone/Fax

Practice location:
  • Phone: 773-330-7861
  • Fax:
Mailing address:
  • Phone: 773-330-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041520238
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: