Provider Demographics
NPI:1396170205
Name:HARWEGER, JACK S (APN)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:S
Last Name:HARWEGER
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 857
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-0857
Mailing Address - Country:US
Mailing Address - Phone:815-599-7950
Mailing Address - Fax:
Practice Address - Street 1:1036 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4865
Practice Address - Country:US
Practice Address - Phone:815-599-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-358671163W00000X
IL209-010694207RG0100X, 363L00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No163W00000XNursing Service ProvidersRegistered Nurse
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$0001Medicaid
IL$$$$$$$$$0001Medicaid