Basic Information
| Provider Information | |||||||||
| NPI: | 1003152778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OFFENBACH | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2753 N WAYNE AVE | ||||||||
| Address2: | UNIT C | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606141260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474362995 | ||||||||
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| Practice Location | |||||||||
| Address1: | 225 E CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122274000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2012 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041363279 | IL | N | Nursing Service Providers | Registered Nurse | 363LP0200X | 209010059 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.