MEDICARE: MRS. ELIZABETH SUE JENNINGS-PORTER CNM

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	367A00000X	Advanced Practice Midwife	209-000734	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05032022	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1114929452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH SUE JENNINGS-PORTER CNM

Provider Business Mailing Address
First Line	:	2220 MARQUETTE RD
Second Line	:
City	:	PERU
State	:	IL
Zip	:	61354-1538
Country	:	US
Telephone Number	:	815-220-0260
Fax Number	:	815-220-8253

Provider Business Practice Location Address
First Line	:	2220 MARQUETTE RD
Second Line	:
City	:	PERU
State	:	IL
Zip	:	61354-1538
Country	:	US
Telephone Number	:	815-220-0260
Fax Number	:	815-220-8253

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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