Provider Demographics
NPI:1265675490
Name:MUNDY, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MUNDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:ROSS-BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3831
Mailing Address - Country:US
Mailing Address - Phone:217-429-9700
Mailing Address - Fax:217-429-9702
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:SUITE 207
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3831
Practice Address - Country:US
Practice Address - Phone:217-429-9700
Practice Address - Fax:217-429-9702
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007079363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily