Healthcare Provider Details

I. General information

NPI: 1831769751
Provider Name (Legal Business Name): JESSICA LYNN PETRISKO DNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

2728 N HAMPDEN CT APT 1701
CHICAGO IL
60614-1629
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-8000
  • Fax:
Mailing address:
  • Phone: 708-822-9008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209022027
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: