Provider Demographics
NPI:1457418329
Name:ERVIN, JENISE (FNP)
Entity type:Individual
Prefix:MRS
First Name:JENISE
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENISE
Other - Middle Name:
Other - Last Name:HOPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:514 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1076
Mailing Address - Country:US
Mailing Address - Phone:708-481-8179
Mailing Address - Fax:
Practice Address - Street 1:142 INDIAN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1902
Practice Address - Country:US
Practice Address - Phone:800-971-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001534A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily