MEDICARE: JESSICA PUTNICK SANDSTROM PA-C

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	363A00000X	Physician Assistant	085009412	IL

General Provider Information

NPI Number	:	1639817695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA PUTNICK SANDSTROM PA-C

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE STE 1223
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:	847-982-3172
Fax Number	:

Provider Business Practice Location Address
First Line	:	9977 WOODS DR STE 165
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-1057
Country	:	US
Telephone Number	:	224-364-2273
Fax Number	:

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

Provider Enumeration Date	:	05/20/2022
Last Update Date	:	03/24/2026

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