Healthcare Provider Details

I. General information

NPI: 1730582990
Provider Name (Legal Business Name): JEP HEALTHCARE PROVIDER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 KETTERING RD
MUNDELEIN IL
60060-5364
US

IV. Provider business mailing address

1330 KETTERING RD
MUNDELEIN IL
60060-5364
US

V. Phone/Fax

Practice location:
  • Phone: 847-287-9102
  • Fax: 847-388-4711
Mailing address:
  • Phone: 847-388-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009807
License Number StateIL

VIII. Authorized Official

Name: JOSEPH ESCOBAR
Title or Position: PRESIDENT
Credential: APN
Phone: 847-287-9102