Provider Demographics
NPI:1497836134
Name:JONES, MARY ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARRY ELLEN
Other - Middle Name:
Other - Last Name:KOEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2460
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:872-588-3021
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:872-588-3021
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001058363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK47019Medicare PIN