Provider Demographics
NPI:1629152061
Name:RICHARDS, JEANMARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JEANMARIE
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13937 W MEATH DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-7704
Mailing Address - Country:US
Mailing Address - Phone:815-722-7000
Mailing Address - Fax:815-722-7180
Practice Address - Street 1:72 N CHICAGO ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-4315
Practice Address - Country:US
Practice Address - Phone:815-722-7000
Practice Address - Fax:815-722-7180
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205979Medicare ID - Type UnspecifiedMEDICARE
ILS87704Medicare UPIN