Provider Demographics
NPI:1073524328
Name:GUTSHALL, JENNIFER D (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:GUTSHALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:D
Other - Last Name:JUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:215 E 1ST ST STE 215
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3166
Mailing Address - Country:US
Mailing Address - Phone:815-285-5422
Mailing Address - Fax:815-285-5426
Practice Address - Street 1:215 E 1ST ST STE 215
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3166
Practice Address - Country:US
Practice Address - Phone:815-285-5422
Practice Address - Fax:815-285-5426
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002531363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002531OtherLICENSE