Provider Demographics
NPI:1295278448
Name:JAMBLE, LLC
Entity type:Organization
Organization Name:JAMBLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:POLLYANNA
Authorized Official - Middle Name:C
Authorized Official - Last Name:VUJOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP
Authorized Official - Phone:812-453-2308
Mailing Address - Street 1:131 CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-9228
Mailing Address - Country:US
Mailing Address - Phone:812-453-2308
Mailing Address - Fax:
Practice Address - Street 1:131 CLOVER DR
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-9228
Practice Address - Country:US
Practice Address - Phone:812-453-2308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007868363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS77354Medicare UPIN