Healthcare Provider Details

I. General information

NPI: 1013306240
Provider Name (Legal Business Name): JESSICA WUNDER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 N PAULINA ST
CHICAGO IL
60640
US

IV. Provider business mailing address

405 AMESBURY DR
SMITHVILLE MO
64089-9625
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-9040
  • Fax:
Mailing address:
  • Phone: 402-216-8249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209012424
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: