Healthcare Provider Details

I. General information

NPI: 1396753406
Provider Name (Legal Business Name): JENNIFER L GARSON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 1010
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 1010
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5904
  • Fax:
Mailing address:
  • Phone: 312-942-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-002431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: