Provider Demographics
NPI:1134160401
Name:HEINRICH, JENNIFER J (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:HEINRICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:J
Other - Last Name:NEWTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:421 S RIDGELAND AVE
Mailing Address - Street 2:#2N
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4092
Mailing Address - Country:US
Mailing Address - Phone:773-844-8428
Mailing Address - Fax:
Practice Address - Street 1:5835 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-4067
Practice Address - Country:US
Practice Address - Phone:773-745-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P76725Medicare UPIN
K10803Medicare ID - Type Unspecified