Provider Demographics
NPI:1922512458
Name:DOUGLASS, JENNIFER MAYURI (APN, FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAYURI
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 PFINGSTEN RD STE 360
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1313
Mailing Address - Country:US
Mailing Address - Phone:847-998-4170
Mailing Address - Fax:847-998-4165
Practice Address - Street 1:2050 PFINGSTEN RD STE 360
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1313
Practice Address - Country:US
Practice Address - Phone:847-998-4170
Practice Address - Fax:847-998-4165
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016884363LF0000X
IL209016884363L00000X
IL041.402891163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse