Basic Information
| Provider Information | |||||||||
| NPI: | 1093110827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIRICH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 W. RAND ROAD | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185450 | ||||||||
| FaxNumber: | 8476185459 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 W. RAND ROAD | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476185450 | ||||||||
| FaxNumber: | 8476185459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2014 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2014-0077 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.