Healthcare Provider Details

I. General information

NPI: 1063184026
Provider Name (Legal Business Name): JENNIFER C WICKLATZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W JACKSON BLVD STE 1700
CHICAGO IL
60604-3597
US

IV. Provider business mailing address

111 W JACKSON BLVD STE 1700
CHICAGO IL
60604-3597
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 888-731-8994
  • Fax: 833-775-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11015667
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.024499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: