Individual
JENNIFER L ELLENS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
444 N PARK BLVD, GLEN ELLYN, IL 60137-4622
(630) 469-0045
(630) 469-0645
Mailing address
444 N PARK BLVD, GLEN ELLYN, IL 60137-4622
(630) 469-0045
(630) 469-0645
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036103252
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0222075
BLUE CROSS GROUP NUMBER
IL
05
—
036103252
—
IL
01
—
080174264
MEDICARE RAILROAD
IL
01
—
363149833
TAX IDENTIFICATION NUMBER
IL
01
—
3631498336019001
CDPG HFS PAYEE ID
IL
01
—
487450
MEDICARE GROUP NUMBER
IL
Enumeration date
07/11/2006
Last updated
04/04/2013
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