Provider Demographics
NPI:1518322510
Name:KRULL, JENNIE REBECCA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:REBECCA
Last Name:KRULL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 COUNTRY CLUB RD UNIT 386
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-5585
Mailing Address - Country:US
Mailing Address - Phone:815-501-5048
Mailing Address - Fax:
Practice Address - Street 1:555 S PERRYVILLE RD STE 130
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2527
Practice Address - Country:US
Practice Address - Phone:815-995-2201
Practice Address - Fax:224-999-4002
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000398363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily