Provider Demographics
NPI:1083707756
Name:HULSEN, JENNIFER SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SUSAN
Last Name:HULSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:SUSAN
Other - Last Name:SANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2160 SO ILL RT 157
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:618-692-1212
Mailing Address - Fax:618-692-4875
Practice Address - Street 1:2160 SO ILL RT 157
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-692-1212
Practice Address - Fax:618-692-4875
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110140Medicaid