Provider Demographics
NPI:1801818026
Name:HARTHAN, JENNIFER SUE (OD)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:SUE
Last Name:HARTHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 DEERFIELD RD
Mailing Address - Street 2:APT #405
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3232
Mailing Address - Country:US
Mailing Address - Phone:847-514-8946
Mailing Address - Fax:
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3849
Practice Address - Country:US
Practice Address - Phone:312-949-7000
Practice Address - Fax:312-949-7660
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009882Medicaid
ILK29069Medicare PIN
V09700Medicare UPIN