Healthcare Provider Details

I. General information

NPI: 1386475515
Provider Name (Legal Business Name): JENNIFER JANE RABCHUK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER JANE FITZPATRICK

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 W 111TH ST
OAK LAWN IL
60453-5012
US

IV. Provider business mailing address

306 MARENGO AVE
FOREST PARK IL
60130-1604
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-7377
  • Fax:
Mailing address:
  • Phone: 309-333-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209030569
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.423394
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: