Provider Demographics
NPI:1992291348
Name:JIANG, SONGQUAN (NP)
Entity type:Individual
Prefix:
First Name:SONGQUAN
Middle Name:
Last Name:JIANG
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 1:860 FOREST AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2473
Mailing Address - Country:US
Mailing Address - Phone:773-273-5453
Mailing Address - Fax:
Practice Address - Street 1:860 FOREST AVE UNIT A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2473
Practice Address - Country:US
Practice Address - Phone:773-273-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013070363LA2200X
IL209.013070363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2014006230OtherANCC
IL209013070Medicaid
IL2014006230OtherANCC