Provider Demographics
NPI:1295151967
Name:BROGAN, JAMIE THALE (APN)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:THALE
Last Name:BROGAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:THALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:676 N. SAINT CLAIR ST. 20TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-695-3269
Mailing Address - Fax:312-695-2310
Practice Address - Street 1:675 N. SAINT CLAIR ST 17TH FLOOR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-695-5620
Practice Address - Fax:312-695-2310
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1295151967Medicare UPIN