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NPI Code Detail

MEDICARE: MALLORY ROSE JENSON PA-C

MEDICARE: MALLORY ROSE JENSON 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
1363A00000XPhysician Assistant085004404IL
2363AM0700XMedical Physician Assistant085.004404IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1085.004404OTHERILILLINOIS STATE LICENSE NUMBER
2385003174OTHERILILLINOIS CONTROLLED SUBSTANCE LICENSE

General Provider Information

NPI Number : 1881945558
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALLORY ROSE JENSON PA-C
Provider Business Mailing Address
First Line : 6141 N CICERO AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60646-4303
Country : US
Telephone Number : 224-364-2273
Fax Number : 847-663-8290
Provider Business Practice Location Address
First Line : 6141 N CICERO AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60646-4303
Country : US
Telephone Number : 224-364-2273
Fax Number : 847-663-8290
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2012
Last Update Date : 08/23/2021

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Directions to “ MALLORY ROSE JENSON PA-C” Practice Location

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