Healthcare Provider Details

I. General information

NPI: 1720568207
Provider Name (Legal Business Name): JENNIFER ROSE APPLEQUIST PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST STE 2060
CHICAGO IL
60611-2994
US

IV. Provider business mailing address

259 E ERIE ST STE 2060
CHICAGO IL
60611-2994
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6022
  • Fax: 312-695-5672
Mailing address:
  • Phone: 312-695-6022
  • Fax: 312-695-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006667
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085-006667
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: