Provider Demographics
NPI:1992179972
Name:HANSEN, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2504
Mailing Address - Country:US
Mailing Address - Phone:630-880-6523
Mailing Address - Fax:630-929-8057
Practice Address - Street 1:541 SPRUCE RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2504
Practice Address - Country:US
Practice Address - Phone:630-880-6523
Practice Address - Fax:630-929-8057
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2099042174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D2099042OtherCERTIFICATE OF WAIVER CLIA