Healthcare Provider Details

I. General information

NPI: 1639006604
Provider Name (Legal Business Name): JENNIFER GOOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9356 S COLFAX AVE
CHICAGO IL
60617-4007
US

IV. Provider business mailing address

9356 S COLFAX AVE
CHICAGO IL
60617-4007
US

V. Phone/Fax

Practice location:
  • Phone: 847-350-9326
  • Fax:
Mailing address:
  • Phone: 847-350-9326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: