Healthcare Provider Details

I. General information

NPI: 1669753877
Provider Name (Legal Business Name): KATINA JONKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 08/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 ROOSEVELT RD
GLEN ELLYN IL
60137-5647
US

IV. Provider business mailing address

165 W GARFIELD AVE
ELMHURST IL
60126-3901
US

V. Phone/Fax

Practice location:
  • Phone: 630-858-2930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-040627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: