Provider Demographics
NPI:1528276219
Name:O'BOYLE, JENNIFER S (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:O'BOYLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:JAHNKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 READ ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3265
Mailing Address - Country:US
Mailing Address - Phone:815-838-7965
Mailing Address - Fax:815-838-8011
Practice Address - Street 1:300 READ ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3265
Practice Address - Country:US
Practice Address - Phone:815-838-7965
Practice Address - Fax:815-838-8011
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085000979OtherSTATE LICENSE
ILF400142039OtherMEDICARE PTAN