MEDICARE: JENNIFER LYNN KROLL

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	69309	WI

General Provider Information

NPI Number	:	1558748350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LYNN KROLL

Provider Business Mailing Address
First Line	:	530 NE GLEN OAK AVE
Second Line	:	PEDIATRIC RESIDENCY PROGRAM - UICOMP
City	:	PEORIA
State	:	IL
Zip	:	61637-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1317 E KELLY AVE
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616
Country	:	US
Telephone Number	:	414-899-4563
Fax Number	:

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

Provider Enumeration Date	:	04/30/2015
Last Update Date	:	05/24/2018

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