1730104639 NPI number — JENNIFER M FERNANDEZ PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730104639 NPI number — JENNIFER M FERNANDEZ PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
JENNIFER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730104639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 OAKMONT LN STE 600C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMONT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60559-5548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-575-6200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 US HIGWAY 41
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHERERVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-803-3880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070012582 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 05010965A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1623066 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1619908 . This is a "BCBS IL GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 367885100 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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