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General NPI Number Information
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NPI Number | 1114624244
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Entity Type | Individual
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Provider Name | JACOB THOMAS PEREZ M.S, ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 02/09/2023
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Last Update Date | 02/09/2023
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Provider Practice Location Address
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Address Line | 10001 S WOODLAWN AVE
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City | CHICAGO
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State | IL
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Zip | 60628-1696
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Country | US
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Telephone | 773-291-6173
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Fax |
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Provider Business Mailing Address
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Address Line | 638 LYNN AVE
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City | ROMEOVILLE
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State | IL
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Zip | 60446-1238
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096.005603
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License Number State | IL
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