Healthcare Provider Details

I. General information

NPI: 1104922533
Provider Name (Legal Business Name): JESSE BROWN VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

16908 INGLESIDE AVE
SOUTH HOLLAND IL
60473-3063
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-7718
  • Fax:
Mailing address:
  • Phone: 708-567-5045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code281P00000X
TaxonomyChronic Disease Hospital
License Number041244811
License Number StateIL

VIII. Authorized Official

Name: MS. SHIRLEY ANN CAMPBELL
Title or Position: AMBULATORY CARE NURSE
Credential: RN
Phone: 312-569-7718