Healthcare Provider Details

I. General information

NPI: 1891779146
Provider Name (Legal Business Name): JENNIFER BRATTLAND OTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001A SIXTH ST INTERNAL MEDICINE CLINIC
GREAT LAKES IL
60088-5230
US

IV. Provider business mailing address

3001A SIXTH STREET NAVAL HOSPITAL
GREAT LAKES IL
60088-2833
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-4560
  • Fax: 847-688-2678
Mailing address:
  • Phone: 847-688-4560
  • Fax: 847-688-2678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: