=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407069404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL POKORNY APRN, BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 FLORSHEIM DR
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-247-4000
-----------------------------------------------------
Fax | 847-234-2090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 488 W BUTTERFIELD LN
-----------------------------------------------------
City | ROUND LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60073-5692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-201-7445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------