Provider Demographics
NPI:1902007024
Name:KHOURI, JODI BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:BETH
Last Name:KHOURI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 2000
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3147
Mailing Address - Country:US
Mailing Address - Phone:312-695-5620
Mailing Address - Fax:312-695-7095
Practice Address - Street 1:676 N SAINT CLAIR ST STE 2000
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3147
Practice Address - Country:US
Practice Address - Phone:312-695-5620
Practice Address - Fax:312-695-7095
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6833363A00000X
IL085.002427363AM0700X
IL085002427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-002427OtherIL STATE LIC