Provider Demographics
NPI:1982609343
Name:RICKMAN, JANE A (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:JANE
Middle Name:A
Last Name:RICKMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2202 HARLEM ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-654-5342
Practice Address - Street 1:2202 HARLEM ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-654-5342
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-152963163W00000X
IL209-001566367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00944335OtherRR MEDICARE
IL593490014Medicare PIN
IL204062053Medicare UPIN
IL204061054Medicare PIN