Healthcare Provider Details

I. General information

NPI: 1982304101
Provider Name (Legal Business Name): JAMIE LYNNE GORDON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S WABASH
CHICAGO IL
60605
US

IV. Provider business mailing address

501 S WABASH
CHICAGO IL
60605
US

V. Phone/Fax

Practice location:
  • Phone: 312-341-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.005339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: