Provider Demographics
NPI:1891110532
Name:JENNETTE, LINDA SUE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUE
Last Name:JENNETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:SUE
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1203
Mailing Address - Country:US
Mailing Address - Phone:618-842-2611
Mailing Address - Fax:
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1206
Practice Address - Country:US
Practice Address - Phone:618-842-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011264367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered