1265774806 NPI number — MRS. JESSICA E. RODRIGUEZ PA

Table of content: EMMA GRACE MASHBURN PA-C (NPI 1679283386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265774806 NPI number — MRS. JESSICA E. RODRIGUEZ PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
JESSICA
Provider Middle Name:
E.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EISENHAUER
Provider Other First Name:
JESSICA
Provider Other Middle Name:
E.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1265774806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 W OGDEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINSDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60521-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-323-6116
Provider Business Mailing Address Fax Number:
630-794-8615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1870 SILVER CROSS BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451-8639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-462-3474
Provider Business Practice Location Address Fax Number:
630-794-8615
Provider Enumeration Date:
03/21/2013

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: 363AS0400X , with the licence number:  085004671 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 085004617 . This is a "PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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