Healthcare Provider Details

I. General information

NPI: 1528638020
Provider Name (Legal Business Name): JACQUELINE COFFER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E SIBLEY BLVD
SOUTH HOLLAND IL
60473-1166
US

IV. Provider business mailing address

4102 W GLADYS AVE
CHICAGO IL
60624-2729
US

V. Phone/Fax

Practice location:
  • Phone: 773-233-4100
  • Fax:
Mailing address:
  • Phone: 773-807-8036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28283705A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041246157
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: