Basic Information
| Provider Information | |||||||||
| NPI: | 1427065200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDENS | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 DELNOR DR | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 DELNOR DR | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302320280 | ||||||||
| FaxNumber: | 6302323895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 12/08/2012 | ||||||||
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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 | 363LA2100X | 209001556 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 209001556 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P01093149 | 01 | IL | MEDICARE RAILROAD PTAN (INDIVIDUAL) | OTHER | 041263676 | 01 | IL | STATE LICENSE | OTHER | 206147 | 01 | IL | MEDICARE PTAN (GROUP) | OTHER | CA4748 | 01 | IL | MEDICARE RAILROAD PTAN (GROUP) | OTHER | 206147100 | 01 | IL | MEDICARE PTAN (INDIVIDUAL) | OTHER |