Provider Demographics
NPI:1801341136
Name:JENKINS, AMANDA (APN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N HAMMES AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8118
Mailing Address - Country:US
Mailing Address - Phone:815-741-2285
Mailing Address - Fax:815-741-2285
Practice Address - Street 1:310 N HAMMES AVE
Practice Address - Street 2:STE 202
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8118
Practice Address - Country:US
Practice Address - Phone:815-741-2285
Practice Address - Fax:815-741-2285
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014635363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204720Medicare UPIN