Provider Demographics
NPI:1669012837
Name:KAMENSKE, JACK ALAN (MSN, RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALAN
Last Name:KAMENSKE
Suffix:
Gender:M
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:16452 BOARDWALK TER
Mailing Address - Street 2:
Mailing Address - City:ORLAND HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60487-5617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12251 S 80TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:773-432-4800
Practice Address - Fax:844-805-4742
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020706363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily