Basic Information
| Provider Information | |||||||||
| NPI: | 1922421643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACINE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 N WELLS ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606146001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003238622 | ||||||||
| FaxNumber: | 2242250376 | ||||||||
| Practice Location | |||||||||
| Address1: | 3718 N ASHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606134793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733279900 | ||||||||
| FaxNumber: | 7733270589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2014 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2090111171 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209011171 | 01 | IL | LICENSE | OTHER |