Healthcare Provider Details

I. General information

NPI: 1588299598
Provider Name (Legal Business Name): JINCY EAPEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 GLENDALE ST
WHEELING IL
60090-2932
US

IV. Provider business mailing address

50 GLENDALE ST
WHEELING IL
60090-2932
US

V. Phone/Fax

Practice location:
  • Phone: 847-912-9670
  • Fax:
Mailing address:
  • Phone: 847-912-9670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021007
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: