MEDICARE: JENNIFER MARIE POLIWKA MSN/MPH, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041376117	IL
2	163W00000X	Registered Nurse	R211984	MD

General Provider Information

NPI Number	:	1386029676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MARIE POLIWKA MSN/MPH, RN

Provider Business Mailing Address
First Line	:	130 WASHINGTON AVE
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1122
Country	:	US
Telephone Number	:	847-909-2004
Fax Number	:	847-433-8906

Provider Business Practice Location Address
First Line	:	130 WASHINGTON AVE
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1122
Country	:	US
Telephone Number	:	847-909-2004
Fax Number	:	847-433-8906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2015
Last Update Date	:	07/28/2015

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