Provider Demographics
NPI:1841806890
Name:JERGE, KATHERINE DEVEREAUX
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DEVEREAUX
Last Name:JERGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10118 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4383
Mailing Address - Country:US
Mailing Address - Phone:219-314-2102
Mailing Address - Fax:
Practice Address - Street 1:2500 S HIGHLAND AVE STE 320
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5390
Practice Address - Country:US
Practice Address - Phone:833-257-7546
Practice Address - Fax:630-495-1770
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009095363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program