Provider Demographics
NPI:1295814572
Name:PRYBELL, JERILYN KAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JERILYN
Middle Name:KAY
Last Name:PRYBELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JERILYN
Other - Middle Name:KAY
Other - Last Name:KOFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:27428 LA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-5002
Mailing Address - Country:US
Mailing Address - Phone:847-623-3937
Mailing Address - Fax:847-623-9836
Practice Address - Street 1:312 TRI STATE PKWY
Practice Address - Street 2:STE 100
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5283
Practice Address - Country:US
Practice Address - Phone:847-623-3937
Practice Address - Fax:847-623-9836
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU20709Medicare UPIN