Provider Demographics
NPI:1114363470
Name:FRYE, JENNIFER A (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:A
Last Name:FRYE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1463
Mailing Address - Country:US
Mailing Address - Phone:815-942-2932
Mailing Address - Fax:
Practice Address - Street 1:5 N JOHNSON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:IL
Practice Address - Zip Code:60541-0002
Practice Address - Country:US
Practice Address - Phone:815-695-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400110608Medicare PIN