Provider Demographics
NPI:1124395199
Name:TIESENGA, JUCY (NP)
Entity Type:Individual
Prefix:MRS
First Name:JUCY
Middle Name:
Last Name:TIESENGA
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 1:1880 W WINCHESTER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5336
Mailing Address - Country:US
Mailing Address - Phone:847-247-0187
Mailing Address - Fax:
Practice Address - Street 1:25 N WINFIELD RD STE 420
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1222
Practice Address - Country:US
Practice Address - Phone:630-682-8700
Practice Address - Fax:630-352-5582
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009046363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health