Provider Demographics
NPI:1598872368
Name:DOUGHERTY, JEANNE (APN)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3617
Mailing Address - Country:US
Mailing Address - Phone:708-229-6985
Mailing Address - Fax:708-229-6931
Practice Address - Street 1:9800 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3617
Practice Address - Country:US
Practice Address - Phone:708-229-6985
Practice Address - Fax:708-229-6931
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209003268OtherLICENSE