Healthcare Provider Details

I. General information

NPI: 1851067243
Provider Name (Legal Business Name): JESSICA LYNN SUPERS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W LAWRENCE AVE
CHICAGO IL
60640-4002
US

IV. Provider business mailing address

5024 N WINTHROP AVE APT 3W
CHICAGO IL
60640-6439
US

V. Phone/Fax

Practice location:
  • Phone: 773-334-3736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051305165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: