Healthcare Provider Details

I. General information

NPI: 1043123250
Provider Name (Legal Business Name): JAYNE PHETTHONGSY
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: JAYNE DOMINGO

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4885 HOFFMAN BLVD STE 100
HOFFMAN ESTATES IL
60192-3727
US

IV. Provider business mailing address

4885 HOFFMAN BLVD STE 100
HOFFMAN ESTATES IL
60192-3727
US

V. Phone/Fax

Practice location:
  • Phone: 847-645-1443
  • Fax: 708-202-5456
Mailing address:
  • Phone: 847-645-1443
  • Fax: 708-202-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043104673
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: