Provider Demographics
NPI:1124794920
Name:GERBER, JONATHAN D (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:GERBER
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W WINNEMAC AVE # B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7893
Mailing Address - Country:US
Mailing Address - Phone:260-580-3886
Mailing Address - Fax:
Practice Address - Street 1:9000 WAUKEGAN RD STE 200
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2127
Practice Address - Country:US
Practice Address - Phone:847-375-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN29352081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000050798OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER