=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699042440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASUNCION GONZALES JISON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2011
-----------------------------------------------------
Last Update Date | 11/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12819 S PONDEROSA DR
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-448-2185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12819 S PONDEROSA DR
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 0365671
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------