Healthcare Provider Details

I. General information

NPI: 1386199396
Provider Name (Legal Business Name): JENNIFER ELISE SOMMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 RANDOLPH RD STE 216
CHARLOTTE NC
28207-1106
US

IV. Provider business mailing address

901 MCCLINTOCK DR STE 202
BURR RIDGE IL
60527-0871
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-5330
  • Fax: 704-316-5332
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-734-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085005854
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13578
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: