Healthcare Provider Details

I. General information

NPI: 1780140806
Provider Name (Legal Business Name): JESSICA ROSE URBACH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 S 80TH AVE STE 204
PALOS HEIGHTS IL
60463-1284
US

IV. Provider business mailing address

12255 S 80TH AVE STE 204
PALOS HEIGHTS IL
60463-1284
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-5900
  • Fax: 708-923-8599
Mailing address:
  • Phone: 708-923-5900
  • Fax: 708-923-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006946
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: