Healthcare Provider Details

I. General information

NPI: 1003691585
Provider Name (Legal Business Name): JANE WONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST FL 17
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

259 E ERIE ST FL 17
CHICAGO IL
60611-2987
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-4566
  • Fax: 312-926-6511
Mailing address:
  • Phone: 312-926-4566
  • Fax: 312-926-6511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209028201
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.028201
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041.391087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: