Basic Information
| Provider Information | |||||||||
| NPI: | 1629471776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 SINCLAIR AVE | ||||||||
| Address2: | 1F | ||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023762 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3860 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606232460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8725883024 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2014 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.005232 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085005232 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 385003893 | 01 | IL | CS LICENSE | OTHER | 085005232 | 01 | IL | STATE LICENSE | OTHER | MB3360978 | 01 | IL | DEA | OTHER | 1121877 | 01 | IL | SPECIALTY BOARDS | OTHER |