Provider Demographics
NPI:1659047058
Name:LUSSENHOP, JENNIFER C
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:LUSSENHOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 S PRINCETON AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4763
Mailing Address - Country:US
Mailing Address - Phone:248-505-9012
Mailing Address - Fax:
Practice Address - Street 1:2822 E 83RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2105
Practice Address - Country:US
Practice Address - Phone:773-721-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant