Healthcare Provider Details

I. General information

NPI: 1982269379
Provider Name (Legal Business Name): JESSICA M KUNKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

IV. Provider business mailing address

2438 W HURON ST
CHICAGO IL
60612-1208
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2000
  • Fax:
Mailing address:
  • Phone: 630-251-4797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.019058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: