Provider Demographics
NPI:1013293547
Name:CARLSEN, JEREMY PHILIP (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:PHILIP
Last Name:CARLSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 W PRATT BLVD
Mailing Address - Street 2:APT 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4382
Mailing Address - Country:US
Mailing Address - Phone:847-769-4836
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:FEINBERG 5-704
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-8369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.356505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered