Provider Demographics
NPI:1558585646
Name:SAMUELS, JANE K (APN)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:K
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:K
Other - Last Name:WILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:WALGREENS 375 E DUNDEE RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074
Practice Address - Country:US
Practice Address - Phone:847-361-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL037518122363LF0000X
IL209-004947363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46171Medicare UPIN
ILK17726Medicare UPIN
ILK46170Medicare UPIN