Provider Demographics
NPI:1649244336
Name:HUGULEY, JACK GLENN (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:GLENN
Last Name:HUGULEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:DEPT 5390
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-0544
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-5020
Practice Address - Street 1:811 SOUTH STATE STREET
Practice Address - Street 2:SUITEB
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-0000
Practice Address - Country:US
Practice Address - Phone:312-566-9510
Practice Address - Fax:312-566-9511
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16498364SE0003X
IL085003674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003674OtherIL PA LICENSE
IL213992Medicare PIN
IL085003674OtherIL PA LICENSE
IL204591Medicare PIN