Provider Demographics
NPI:1326224338
Name:WHITE, JESSICA T (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:T
Last Name:WHITE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-0443
Mailing Address - Country:US
Mailing Address - Phone:773-355-5300
Mailing Address - Fax:
Practice Address - Street 1:8420 W BRYN MAWR AVE STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3436
Practice Address - Country:US
Practice Address - Phone:773-355-5300
Practice Address - Fax:773-714-1229
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006937207L00000X
IL209.006937367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
01623422OtherBCBS ID IL
ILK49287Medicare PIN
01623422OtherBCBS ID IL