Provider Demographics
NPI:1164515326
Name:THURMOND, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:THURMOND
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 1:444 N EOLA RD STE 110
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-9619
Mailing Address - Country:US
Mailing Address - Phone:630-692-5330
Mailing Address - Fax:630-692-5661
Practice Address - Street 1:444 N EOLA RD STE 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9619
Practice Address - Country:US
Practice Address - Phone:630-692-5660
Practice Address - Fax:630-692-5661
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000636363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209004247Medicaid
IL209004247Medicaid