Healthcare Provider Details

I. General information

NPI: 1114624244
Provider Name (Legal Business Name): JACOB THOMAS PEREZ M.S, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 S WOODLAWN AVE
CHICAGO IL
60628-1696
US

IV. Provider business mailing address

638 LYNN AVE
ROMEOVILLE IL
60446-1238
US

V. Phone/Fax

Practice location:
  • Phone: 773-291-6173
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.005603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: