Provider Demographics
NPI: | 1558694190 |
---|---|
Name: | POELL, JENIFER ANN (CNM, WHNP-BC, MSN) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | JENIFER |
Middle Name: | ANN |
Last Name: | POELL |
Suffix: | |
Gender: | F |
Credentials: | CNM, WHNP-BC, MSN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1701 W SUPERIOR ST # 3 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60622-5646 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 312-666-3494 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1701 W SUPERIOR ST # 3 |
Practice Address - Street 2: | |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60622-5646 |
Practice Address - Country: | US |
Practice Address - Phone: | 312-666-3494 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-09-15 |
Last Update Date: | 2021-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 209007909 | 363L00000X |
IL | 209007577 | 367A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 209007577 | Other | LICENSE |