Provider Demographics
NPI:1386199396
Name:SOMMER, JENNIFER ELISE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELISE
Last Name:SOMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:STE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0871
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:1900 RANDOLPH RD STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1106
Practice Address - Country:US
Practice Address - Phone:704-316-5330
Practice Address - Fax:704-316-5332
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005854363AM0700X
NC0010-13578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-005854OtherIL LICENSE
IL085-005854OtherIL LICENSE
ILF400322453Medicare PIN