Healthcare Provider Details

I. General information

NPI: 1114257375
Provider Name (Legal Business Name): JENNIFER KHAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BRIZIC

II. Dates (important events)

Enumeration Date: 01/10/2010
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

1464 S MICHIGAN AVE 1207
CHICAGO IL
60605-3711
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 708-955-6815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.007943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: