Provider Demographics
NPI:1114401833
Name:TARVESTAD, JENNIFER (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TARVESTAD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3027 PERRY RD
Mailing Address - Street 2:
Mailing Address - City:STEWARD
Mailing Address - State:IL
Mailing Address - Zip Code:60553-9702
Mailing Address - Country:US
Mailing Address - Phone:815-440-6734
Mailing Address - Fax:
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:815-756-4892
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017958363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner