Provider Demographics
NPI:1780764175
Name:FRESNE, JANE (DN)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:
Last Name:FRESNE
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 DAVIS ST STE 815
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4655
Mailing Address - Country:US
Mailing Address - Phone:847-425-9120
Mailing Address - Fax:773-687-4637
Practice Address - Street 1:500 DAVIS ST STE 815
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4655
Practice Address - Country:US
Practice Address - Phone:847-425-9120
Practice Address - Fax:773-687-4637
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001635232OtherBCBS PROVIDER NUMBER