Healthcare Provider Details

I. General information

NPI: 1578106514
Provider Name (Legal Business Name): JEVONNE RENEE HORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N ASHLAND AVE
CHICAGO IL
60607-1802
US

IV. Provider business mailing address

140 N ASHLAND AVE
CHICAGO IL
60607-1802
US

V. Phone/Fax

Practice location:
  • Phone: 312-850-0050
  • Fax:
Mailing address:
  • Phone: 312-633-4977
  • Fax: 312-850-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043069789
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: