Provider Demographics
NPI:1912756453
Name:GUTIERREZ, JAMIE L
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:L
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:29624 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1296
Mailing Address - Country:US
Mailing Address - Phone:608-741-7652
Mailing Address - Fax:
Practice Address - Street 1:875 S ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8190
Practice Address - Country:US
Practice Address - Phone:779-220-5500
Practice Address - Fax:779-220-5184
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009914225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant