Provider Demographics
NPI:1992023535
Name:RUSSO, JEAN A (CPNP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:A
Other - Last Name:KOPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:4709 GOLF RD STE 900
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1244
Mailing Address - Country:US
Mailing Address - Phone:847-676-5394
Mailing Address - Fax:847-679-7183
Practice Address - Street 1:4709 GOLF RD STE 900
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-676-5394
Practice Address - Fax:847-679-7183
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LP0200X363LP0200X
IL209006848363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics