Provider Demographics
NPI:1073924015
Name:VODICKA, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VODICKA
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 1:13045 RAVINE DR
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-7331
Mailing Address - Country:US
Mailing Address - Phone:630-233-4738
Mailing Address - Fax:630-566-3897
Practice Address - Street 1:13045 RAVINE DR
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-7331
Practice Address - Country:US
Practice Address - Phone:630-233-4738
Practice Address - Fax:630-566-3897
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011388363LF0000X
IL277001756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily