Provider Demographics
NPI:1306829775
Name:WACHTEL, JESSICA M (PA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:M
Last Name:WACHTEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 HAMACHER STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298
Mailing Address - Country:US
Mailing Address - Phone:618-939-3939
Mailing Address - Fax:618-939-3941
Practice Address - Street 1:509 HAMACHER STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298
Practice Address - Country:US
Practice Address - Phone:618-939-3939
Practice Address - Fax:618-939-3941
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
546390OtherMEDICARE-ID-UNSPEC.
Q37491Medicare UPIN
546390OtherMEDICARE-ID-UNSPEC.
IL3374021Medicare PIN
ILIL3374021Medicare PIN
IL546390Medicare ID - Type Unspecified