Healthcare Provider Details

I. General information

NPI: 1023550688
Provider Name (Legal Business Name): JENNIFER WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W ARLINGTON PL APT 801
CHICAGO IL
60614-6429
US

IV. Provider business mailing address

550 W ARLINGTON PL APT 801
CHICAGO IL
60614-6429
US

V. Phone/Fax

Practice location:
  • Phone: 616-402-7013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1033676
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041445801
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number113372
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041445801
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: