Provider Demographics
NPI:1770044711
Name:DANIEL, JESSICA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7026 WILSON TER
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1236
Mailing Address - Country:US
Mailing Address - Phone:773-592-3096
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC-2026
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018583363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner