Individual
JENNIFER R SUNDERLAND
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
250 W KENWOOD AVE, DECATUR, IL 62526-4371
(217) 528-7541
Mailing address
PO BOX 19248, SPRINGFIELD, IL 62794-9248
(217) 528-7541
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085003210
IL
363AM0700X
Medical Physician Assistant
085003210
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
202735
MEDICARE PTAN LOCALITY 15
IL
01
—
215827
MEDICARE PTAN LOCALITY 99
IL
01
—
604530
MEDICARE PTAN LOCALITY 16
IL
Enumeration date
09/11/2006
Last updated
06/25/2025
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