Provider Demographics
NPI:1063966158
Name:PEDERSON, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W GRAND AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5534
Mailing Address - Country:US
Mailing Address - Phone:612-205-7959
Mailing Address - Fax:
Practice Address - Street 1:3 ERIE CT STE 1300
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2519
Practice Address - Country:US
Practice Address - Phone:708-406-3929
Practice Address - Fax:708-406-3935
Is Sole Proprietor?:No
Enumeration Date:2016-08-07
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily