Healthcare Provider Details

I. General information

NPI: 1518193903
Provider Name (Legal Business Name): MR. JESSE HULTSTRAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2009
Last Update Date: 05/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 W CARMEN AVE APT 3N
CHICAGO IL
60640-2953
US

IV. Provider business mailing address

1238 W CARMEN AVE APT 3N
CHICAGO IL
60640-2953
US

V. Phone/Fax

Practice location:
  • Phone: 224-402-3311
  • Fax:
Mailing address:
  • Phone: 224-402-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: