Provider Demographics
NPI:1114360526
Name:FANN, JESSICA M
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:M
Last Name:FANN
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 1:3250 S SHIELDS AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3694
Mailing Address - Country:US
Mailing Address - Phone:312-326-1281
Mailing Address - Fax:
Practice Address - Street 1:3250 S SHIELDS AVE
Practice Address - Street 2:UNIT C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3694
Practice Address - Country:US
Practice Address - Phone:312-326-1281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program