Provider Demographics
NPI:1780140806
Name:URBACH, JESSICA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:URBACH
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 1:12255 S 80TH AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1284
Mailing Address - Country:US
Mailing Address - Phone:708-923-5900
Mailing Address - Fax:708-923-8599
Practice Address - Street 1:12255 S 80TH AVE STE 204
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1284
Practice Address - Country:US
Practice Address - Phone:708-923-5900
Practice Address - Fax:708-923-8599
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085006946OtherSTATE LICENSE