Provider Demographics
NPI:1750480570
Name:JONES, GRETCHEN (PAC)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21W021 PAR LN
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2487
Mailing Address - Country:US
Mailing Address - Phone:630-220-4122
Mailing Address - Fax:888-445-1991
Practice Address - Street 1:21W021 PAR LN
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2487
Practice Address - Country:US
Practice Address - Phone:630-220-4122
Practice Address - Fax:888-445-1991
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCH8564OtherRURAL HEALTH ID#
ILCH8564OtherRURAL HEALTH ID#
IL210027Medicare ID - Type UnspecifiedGROUP ID #
IL36-3167726Medicare ID - Type UnspecifiedGROUP TAX ID#
ILK10778Medicare PIN