Provider Demographics
NPI:1932820800
Name:MARLETT, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MARLETT
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 1:672 BROOKVALE DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-7162
Mailing Address - Country:US
Mailing Address - Phone:708-912-2995
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL209-026547363LN0005X
IL28229612A163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care