Basic Information
Provider Information
NPI: 1306380100
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NESNIDAL
FirstName: JAMIE
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2392 PUTNAM DR
Address2:  
City: NAPERVILLE
State: IL
PostalCode: 605653044
CountryCode: US
TelephoneNumber: 6308539280
FaxNumber:  
Practice Location
Address1: 452 N EOLA RD
Address2: SUITE A
City: AURORA
State: IL
PostalCode: 605029612
CountryCode: US
TelephoneNumber: 6309990401
FaxNumber: 6304239669
Other Information
ProviderEnumerationDate: 12/13/2016
LastUpdateDate: 12/13/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-16-26554ILY    

ID Information
IDTypeStateIssuerDescription
BACB35871101ILBACBOTHER


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