Provider Demographics
NPI:1760967525
Name:KUBIAK, JENELLE (MSN, RN, APNP)
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:KUBIAK
Suffix:
Gender:F
Credentials:MSN, RN, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639295 DEPT 93394
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-266-4200
Mailing Address - Fax:
Practice Address - Street 1:1000 BURR RIDGE PKWY STE 201
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0864
Practice Address - Country:US
Practice Address - Phone:312-818-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI220319-30363L00000X
IL209028017363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner