Basic Information
| Provider Information | |||||||||
| NPI: | 1780338145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRICKETT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4309 W MEDICAL CENTER DR STE B305 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478027400 | ||||||||
| FaxNumber: | 8478027399 | ||||||||
| Practice Location | |||||||||
| Address1: | 4309 W MEDICAL CENTER DR STE B305 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478027400 | ||||||||
| FaxNumber: | 8478027399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209.024712 | IL | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 209024712 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.