Provider Demographics
NPI:1982933974
Name:GONZALEZ, JENNIFER L (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:GONZALEZ
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 1:1001 MAIN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2036
Mailing Address - Country:US
Mailing Address - Phone:309-308-0920
Mailing Address - Fax:309-308-0930
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-655-2045
Practice Address - Fax:309-655-2057
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041309807163W00000X
IL209-008074363L00000X
IL209-003998363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP NUMBER
IL809840OtherMEDICARE GROUP NUMBER