Provider Demographics
NPI:1932198322
Name:CENTORE-LOBER, JENNIFER (PA C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CENTORE-LOBER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0013
Mailing Address - Country:US
Mailing Address - Phone:847-585-7000
Mailing Address - Fax:847-240-0622
Practice Address - Street 1:9711 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1384
Practice Address - Country:US
Practice Address - Phone:847-568-9930
Practice Address - Fax:847-568-9932
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001262363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL218940001Medicare PIN
P39324Medicare UPIN