Healthcare Provider Details

I. General information

NPI: 1649244336
Provider Name (Legal Business Name): JACK GLENN HUGULEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 SOUTH STATE STREET SUITEB
CHICAGO IL
60605-0000
US

IV. Provider business mailing address

PO BOX 544 DEPT 5390
MILWAUKEE WI
53201-0544
US

V. Phone/Fax

Practice location:
  • Phone: 312-566-9510
  • Fax: 312-566-9511
Mailing address:
  • Phone: 815-713-2600
  • Fax: 815-654-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License NumberPA16498
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003674
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: