MEDICARE: JENNIFER TARVESTAD FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	209017958	IL

General Provider Information

NPI Number	:	1114401833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER TARVESTAD FNP-BC

Provider Business Mailing Address
First Line	:	3027 PERRY RD
Second Line	:
City	:	STEWARD
State	:	IL
Zip	:	60553-9702
Country	:	US
Telephone Number	:	815-440-6734
Fax Number	:

Provider Business Practice Location Address
First Line	:	1850 GATEWAY DR
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-758-8671
Fax Number	:	815-756-4892

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2018
Last Update Date	:	12/04/2019

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