Healthcare Provider Details

I. General information

NPI: 1124395199
Provider Name (Legal Business Name): JUCY TIESENGA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WINFIELD RD STE 420
WINFIELD IL
60190-1222
US

IV. Provider business mailing address

1880 W WINCHESTER RD STE 201
LIBERTYVILLE IL
60048-5336
US

V. Phone/Fax

Practice location:
  • Phone: 630-682-8700
  • Fax: 630-352-5582
Mailing address:
  • Phone: 847-247-0187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209009046
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209009046
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: