Provider Demographics
NPI:1225883788
Name:STAMOS, JENNIFER NICOLE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:STAMOS
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 1:12500 S 72ND CT
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1409
Mailing Address - Country:US
Mailing Address - Phone:708-837-0821
Mailing Address - Fax:
Practice Address - Street 1:14301 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-2110
Practice Address - Country:US
Practice Address - Phone:708-498-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program