Healthcare Provider Details

I. General information

NPI: 1104781905
Provider Name (Legal Business Name): JAIME GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S GREENLEAF ST STE 403
GURNEE IL
60031-5709
US

IV. Provider business mailing address

900 RAND RD STE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 847-596-7640
  • Fax: 847-596-7641
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-009205
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: