Provider Demographics
NPI:1356753016
Name:OTTENHEIMER, JENNAFER BIRNE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNAFER
Middle Name:BIRNE
Last Name:OTTENHEIMER
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 1:1000 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:847-582-2134
Mailing Address - Fax:847-535-7285
Practice Address - Street 1:1000 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-582-2134
Practice Address - Fax:847-535-7285
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant