Healthcare Provider Details

I. General information

NPI: 1750401303
Provider Name (Legal Business Name): JILL P PANKUS PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 HARRISON ST
BARRINGTON IL
60010-3007
US

IV. Provider business mailing address

3600 W FULLERTON AVENUE
CHICAGO IL
60647
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-7618
  • Fax: 847-381-9198
Mailing address:
  • Phone: 773-782-2800
  • Fax: 773-782-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209001706
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: