Provider Demographics
NPI:1720397714
Name:ODIAGA, JAN (DNP CPNP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:ODIAGA
Suffix:
Gender:F
Credentials:DNP CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 DUNDEE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 DUNDEE AVE
Practice Address - Street 2:
Practice Address - City:EAST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-1642
Practice Address - Country:US
Practice Address - Phone:847-844-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-25
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.003792363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics