Individual
JESSIE HANSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
541 SPRUCE RD, BOLINGBROOK, IL 60440-2504
(630) 880-6523
(630) 929-8057
Mailing address
541 SPRUCE RD, BOLINGBROOK, IL 60440-2504
(630) 880-6523
(630) 929-8057
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
14D2099042
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14D2099042
CERTIFICATE OF WAIVER CLIA
IL
Enumeration date
11/13/2015
Last updated
11/13/2015
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