Provider Demographics
NPI:1427065200
Name:EDENS, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EDENS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 DELNOR DR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4220
Mailing Address - Country:US
Mailing Address - Phone:630-232-0280
Mailing Address - Fax:630-232-3895
Practice Address - Street 1:351 DELNOR DR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4220
Practice Address - Country:US
Practice Address - Phone:630-232-0280
Practice Address - Fax:630-232-3895
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001556363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01093149OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
IL041263676OtherSTATE LICENSE
IL206147OtherMEDICARE PTAN (GROUP)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)
IL206147100OtherMEDICARE PTAN (INDIVIDUAL)
IL$$$$$$$$$001Medicaid
ILP01093149OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)