Healthcare Provider Details

I. General information

NPI: 1992087852
Provider Name (Legal Business Name): DANIELLE RENE JAKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1799 KINGS GATE LN
CRYSTAL LAKE IL
60014-2906
US

IV. Provider business mailing address

547 W PARK AVE UNIT A
LIBERTYVILLE IL
60048-2666
US

V. Phone/Fax

Practice location:
  • Phone: 815-276-7786
  • Fax: 815-788-1321
Mailing address:
  • Phone: 224-374-9180
  • Fax: 815-788-1321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: