Provider Demographics
NPI:1720793052
Name:GUDGEL, JENNIFER M (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:GUDGEL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 W MORTON AVE STE 22
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-4021
Mailing Address - Country:US
Mailing Address - Phone:217-588-6140
Mailing Address - Fax:217-588-3043
Practice Address - Street 1:901 W MORTON AVE STE 22
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-4021
Practice Address - Country:US
Practice Address - Phone:217-588-6140
Practice Address - Fax:217-527-3043
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041393189163W00000X
IL209026802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.026802OtherAPN
IL041393189OtherRN LICENSE