Provider Demographics
NPI:1790868347
Name:JELLEN, KAREN VIVIAN (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:VIVIAN
Last Name:JELLEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3839 N JANSSEN AVE
Mailing Address - Street 2:APT. 1E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3745
Mailing Address - Country:US
Mailing Address - Phone:312-404-7581
Mailing Address - Fax:773-564-5886
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5880
Practice Address - Fax:773-564-5886
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ21359Medicare UPIN