Provider Demographics
NPI:1598209827
Name:ANDERSON, JAYMINE (AGPCNP)
Entity Type:Individual
Prefix:
First Name:JAYMINE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 S MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1426
Mailing Address - Country:US
Mailing Address - Phone:773-834-0152
Mailing Address - Fax:773-834-8891
Practice Address - Street 1:5700 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:773-834-0152
Practice Address - Fax:773-834-8891
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015026363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner