Provider Demographics
NPI:1184987497
Name:BARHAM, JENNIFER K (ANP-BC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:K
Last Name:BARHAM
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:POST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-858-4106
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:1530 N RANDALL RD STE 210
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7879
Practice Address - Country:US
Practice Address - Phone:224-760-7322
Practice Address - Fax:224-535-8252
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-009597363L00000X
IL209009597363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147238OtherMEDICARE PTAN
IL206147OtherMEDICARE PTAN (GROUP)
IL209-009597OtherLICENSE
IL206147238OtherMEDICARE PTAN