Provider Demographics
NPI:1588764062
Name:DUDAK, JENNIFER ANN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:DUDAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:18425 W CREEK DR STE F
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6768
Mailing Address - Country:US
Mailing Address - Phone:708-444-8300
Mailing Address - Fax:708-444-8301
Practice Address - Street 1:908 N ELM ST
Practice Address - Street 2:SUITE 300
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3625
Practice Address - Country:US
Practice Address - Phone:630-455-1756
Practice Address - Fax:630-455-1759
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001954OtherLICENSE
IL1056683OtherCERTIFICATE NUMBER
IL050540914OtherGROUP TAX ID #
ILP00382533/CK6882OtherRAILROAD MEDICARE PIN
IL050540914OtherGROUP TAX ID #
ILP00382533/CK6882OtherRAILROAD MEDICARE PIN
ILK36268/203980Medicare PIN