Provider Demographics
NPI:1912247081
Name:MATTHEWS, JASMINE NICOLE-CHURCHILL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JASMINE
Middle Name:NICOLE-CHURCHILL
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:NICOLE
Other - Last Name:CHURCHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:251 E HURON ST STE 5-704
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:312-695-0061
Mailing Address - Fax:312-695-9013
Practice Address - Street 1:251 E HURON ST STE 5-704
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-695-0061
Practice Address - Fax:312-695-9013
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030922363AS0400X
IL085007227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC297256ZBPZMedicaid