Provider Demographics
NPI:1003815770
Name:JAESCHKE, SANDRA (CNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:JAESCHKE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATION DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:815-455-8044
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP44554Medicare UPIN
ILK10485Medicare PIN
IL962341Medicare PIN
ILK10486Medicare PIN
ILP00327403Medicare PIN