Provider Demographics
NPI:1174891758
Name:WILLIS, JENNIFER L (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-1601
Mailing Address - Country:US
Mailing Address - Phone:773-224-1211
Mailing Address - Fax:773-224-1810
Practice Address - Street 1:11 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1601
Practice Address - Country:US
Practice Address - Phone:773-224-1211
Practice Address - Fax:773-224-1810
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049127017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8209232232Medicaid
IL8209232Medicaid
IL8209232Medicare PIN
IL8209232Medicare Oscar/Certification
IL8209232Medicaid
IL8209232Medicare UPIN
IL8209232232Medicaid
IL8209232232Medicare UPIN
IL8203232232Medicare Oscar/Certification