Healthcare Provider Details

I. General information

NPI: 1356733034
Provider Name (Legal Business Name): JESSICA LYNN DYE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE SUITE 607
MELROSE PARK IL
60160-1634
US

IV. Provider business mailing address

5448 W GRACE ST
CHICAGO IL
60641-3211
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-7809
  • Fax: 708-681-7808
Mailing address:
  • Phone: 479-427-9175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005374
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: