Healthcare Provider Details

I. General information

NPI: 1760430516
Provider Name (Legal Business Name): JENNIFER K JENSEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N DAYTON ST FL 3
CHICAGO IL
60642-2644
US

IV. Provider business mailing address

225 E CHICAGO AVE BOX 161B
CHICAGO IL
60611-2605
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-6005
  • Fax: 312-227-9446
Mailing address:
  • Phone: 312-227-6005
  • Fax: 312-227-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number209003709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: