Healthcare Provider Details

I. General information

NPI: 1710237748
Provider Name (Legal Business Name): JUSTIN W JELINSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S MILWAUKEE AVE
LIBERTYVILLE IL
60048-3279
US

IV. Provider business mailing address

2030 E MAIN ST
GALESBURG IL
61401-5460
US

V. Phone/Fax

Practice location:
  • Phone: 847-362-1848
  • Fax: 847-362-3351
Mailing address:
  • Phone: 309-343-3570
  • Fax: 309-343-3571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001450A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: