Provider Demographics
NPI:1689100083
Name:SEDLACEK, JENNIFER (FNP, CNP, RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SEDLACEK
Suffix:
Gender:F
Credentials:FNP, CNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SUNSET PT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1031
Mailing Address - Country:US
Mailing Address - Phone:618-267-2174
Mailing Address - Fax:
Practice Address - Street 1:119 SUNSET PT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1031
Practice Address - Country:US
Practice Address - Phone:618-267-2174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14142132081163W00000X
MO2009018563163W00000X
KS5377935081363LF0000X
IL041379873163W00000X
MO2017027608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily