Provider Demographics
NPI:1700509643
Name:VOGT, JENNA JULIANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:JULIANNA
Last Name:VOGT
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 1:39 THORNHILL CT
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6446
Mailing Address - Country:US
Mailing Address - Phone:630-390-9303
Mailing Address - Fax:
Practice Address - Street 1:500 E 51ST ST STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2494
Practice Address - Country:US
Practice Address - Phone:312-572-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.009258363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty