Healthcare Provider Details

I. General information

NPI: 1518322510
Provider Name (Legal Business Name): JENNIE REBECCA KRULL PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S PERRYVILLE RD STE 130
ROCKFORD IL
61108-2527
US

IV. Provider business mailing address

1050 COUNTRY CLUB RD UNIT 386
WOODSTOCK IL
60098-5585
US

V. Phone/Fax

Practice location:
  • Phone: 815-995-2201
  • Fax: 224-999-4002
Mailing address:
  • Phone: 815-501-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number277000398
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number277000398
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number377000394
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000398
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: