Provider Demographics
NPI:1740812502
Name:PETERLIN, JENNIFER JOAN (RN, MSN, AGNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOAN
Last Name:PETERLIN
Suffix:
Gender:F
Credentials:RN, MSN, AGNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JOAN
Other - Last Name:TANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, AGNP
Mailing Address - Street 1:5841 S MARYLAND AVE # MC5067
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1443
Mailing Address - Country:US
Mailing Address - Phone:773-702-1611
Mailing Address - Fax:773-834-7071
Practice Address - Street 1:5700 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:312-933-1159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019384363L00000X
IL041.334334163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care