Provider Demographics
NPI:1407182322
Name:WERNIKOFF, JODI B (PA-C)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:B
Last Name:WERNIKOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CSH
Mailing Address - Street 2:
Mailing Address - City:YOUNGSUN
Mailing Address - State:SEOUL
Mailing Address - Zip Code:96205 5244
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 CSH
Practice Address - Street 2:UNIT 15244
Practice Address - City:YOUNGSUN
Practice Address - State:SEOUL
Practice Address - Zip Code:96205 5244
Practice Address - Country:KR
Practice Address - Phone:847-650-0852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1087140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant