Provider Demographics
NPI:1447526322
Name:TRUESDALE, JENNIFER MARIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:TRUESDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18646 GOLFVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18646 GOLFVIEW AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3608
Practice Address - Country:US
Practice Address - Phone:708-337-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28200184A163W00000X
IL041351556163W00000X
IN088037367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse