Provider Demographics
NPI:1134639008
Name:SCHAFER, JESSICA (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SCHAFER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W GRANT PL APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3808
Mailing Address - Country:US
Mailing Address - Phone:480-205-5112
Mailing Address - Fax:
Practice Address - Street 1:9760 S KEDZIE AVE STE 3
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3184
Practice Address - Country:US
Practice Address - Phone:708-423-6209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006381363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant