Healthcare Provider Details

I. General information

NPI: 1427566454
Provider Name (Legal Business Name): JACK M PHAM DNP, APRNFPA, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4947 N WINTHROP AVE
CHICAGO IL
60640-3607
US

IV. Provider business mailing address

4947 N WINTHROP AVE MEDICAL CENTER FLR 1
CHICAGO IL
60640-3607
US

V. Phone/Fax

Practice location:
  • Phone: 773-455-4325
  • Fax: 773-838-0902
Mailing address:
  • Phone: 773-455-4325
  • Fax: 773-838-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277005652
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277005652
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number277005652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: