Healthcare Provider Details

I. General information

NPI: 1659846301
Provider Name (Legal Business Name): JULIE L VIVANCO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE VIVANCO JACKSON

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 W FULTON ST
CHICAGO IL
60612-2345
US

IV. Provider business mailing address

2003 W FULTON ST
CHICAGO IL
60612-2345
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-2223
  • Fax: 312-243-2227
Mailing address:
  • Phone: 312-243-2223
  • Fax: 312-243-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209029725
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: