Provider Demographics
NPI:1659475655
Name:SUNDERLAND, JENNIFER R (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3803
Practice Address - Country:US
Practice Address - Phone:217-464-1200
Practice Address - Fax:217-464-1210
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202735OtherMEDICARE PTAN LOCALITY 15
IL215827OtherMEDICARE PTAN LOCALITY 99
IL604530OtherMEDICARE PTAN LOCALITY 16
P95820Medicare UPIN
IL215827OtherMEDICARE PTAN LOCALITY 99
ILK51271Medicare PIN