Healthcare Provider Details

I. General information

NPI: 1295814572
Provider Name (Legal Business Name): JERILYN KAY PRYBELL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JERILYN KAY KOFMAN O.D.

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 05/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 TRI STATE PKWY STE 100
GURNEE IL
60031-5283
US

IV. Provider business mailing address

27428 LA VISTA DR
MUNDELEIN IL
60060-5002
US

V. Phone/Fax

Practice location:
  • Phone: 847-623-3937
  • Fax: 847-623-9836
Mailing address:
  • Phone: 847-623-3937
  • Fax: 847-623-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008426
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: