Healthcare Provider Details

I. General information

NPI: 1538261524
Provider Name (Legal Business Name): JAENA S GONZAGA D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E CHICAGO ST
ELGIN IL
60120-6502
US

IV. Provider business mailing address

657 FIELDCREST DR UNIT B
SOUTH ELGIN IL
60177-3429
US

V. Phone/Fax

Practice location:
  • Phone: 847-468-6012
  • Fax: 847-468-6013
Mailing address:
  • Phone: 847-608-5215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: