Provider Demographics
NPI:1528638020
Name:COFFER, JACQUELINE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:COFFER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 W GLADYS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2729
Mailing Address - Country:US
Mailing Address - Phone:773-807-8036
Mailing Address - Fax:
Practice Address - Street 1:901 E SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1166
Practice Address - Country:US
Practice Address - Phone:773-233-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QC1500X
IN28283705A363LF0000X
IL041246157363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health