Healthcare Provider Details

I. General information

NPI: 1841650454
Provider Name (Legal Business Name): JONATHAN HILLIARD LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 N KENMORE AVE
CHICAGO IL
60640-1515
US

IV. Provider business mailing address

5517 N KENMORE AVE
CHICAGO IL
60640-1515
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-7962
  • Fax:
Mailing address:
  • Phone: 773-275-7962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043115141
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27071194A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: