Provider Demographics
NPI:1346793742
Name:STASKOWICZ, JENNIFER (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STASKOWICZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23W149 BLACKCHERRY LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-7244
Mailing Address - Country:US
Mailing Address - Phone:630-474-6081
Mailing Address - Fax:
Practice Address - Street 1:635 N FAIRBANKS CT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5435
Practice Address - Country:US
Practice Address - Phone:312-694-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily