Provider Demographics
NPI:1225438278
Name:KOSHY, JENNY (APRN)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:KOSHY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S GARY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2228
Mailing Address - Country:US
Mailing Address - Phone:630-924-4009
Mailing Address - Fax:630-924-9671
Practice Address - Street 1:5 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3372
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:860-343-7379
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011753363LF0000X, 363L00000X
CT11880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400169410OtherMEDICARE PTAN (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)
IL346761379001Medicaid