Healthcare Provider Details

I. General information

NPI: 1083064679
Provider Name (Legal Business Name): JENNIFER LYNN SGRO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W VAN BUREN ST STE 500
CHICAGO IL
60612-5500
US

IV. Provider business mailing address

1700 W VAN BUREN ST STE 500
CHICAGO IL
60612-5500
US

V. Phone/Fax

Practice location:
  • Phone: 312-947-4663
  • Fax: 312-563-0421
Mailing address:
  • Phone: 312-947-4663
  • Fax: 123-563-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014281
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number209014281
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: