Provider Demographics
NPI:1427566454
Name:PHAM, JACK M (DNP, APRN, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:PHAM
Suffix:
Gender:M
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4947 N WINTHROP AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3607
Mailing Address - Country:US
Mailing Address - Phone:773-455-4325
Mailing Address - Fax:773-838-0902
Practice Address - Street 1:4947 N WINTHROP AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3607
Practice Address - Country:US
Practice Address - Phone:773-455-4325
Practice Address - Fax:773-838-0902
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027448363LF0000X, 363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023019429OtherANCC
IL041460482OtherIDFPR NURSING BOARD