Provider Demographics
NPI:1538323456
Name:THOMAS, JESSY (NP)
Entity Type:Individual
Prefix:MRS
First Name:JESSY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 RAYMOND DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9789
Mailing Address - Country:US
Mailing Address - Phone:630-933-6091
Mailing Address - Fax:630-933-2995
Practice Address - Street 1:636 RAYMOND DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9789
Practice Address - Country:US
Practice Address - Phone:630-933-6091
Practice Address - Fax:630-933-2995
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334729363LF0000X
IL209008189363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041380904Medicaid
IL920540OtherMEDICARE PTAN (GROUP)
ILF400103289Medicare PIN