Provider Demographics
NPI:1912216045
Name:FRITZ, JENNIFER COSTELLO (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:COSTELLO
Last Name:FRITZ
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 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:312-633-5841
Mailing Address - Fax:
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:312-633-5841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant