Provider Demographics
NPI:1386286144
Name:JACKSON-GONZALEZ, ANAIS KAREL
Entity type:Individual
Prefix:
First Name:ANAIS
Middle Name:KAREL
Last Name:JACKSON-GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 CHAPPEL CT APT 103
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-4804
Mailing Address - Country:US
Mailing Address - Phone:312-358-4557
Mailing Address - Fax:
Practice Address - Street 1:2018 S. MICHIGAN AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:312-753-3249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171357171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist