Jaclyn Mary Petrov, APN

Primary specialty

Obstetrics & Gynecology Nurse PractitionerTaxonomy code 363LX0001X

License

209.019158 Issued in IN

Practice address

10260 191St St Ste 100
Mokena, IL 60448-8802

Phone

(708) 572-7669

Fax

(708) 422-4253

NPI assigned

Apr 26, 2019

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Jaclyn Mary Serafin Former name

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Nurse Midwife

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: jaclyn.petrov.p1@direct.northshorehealth.nextgenshare.com
• FHIR API: https://api.platform.athenahealth.com/7833/brand/1/csg/1/fhir/r4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Northshore Health Centers Inc

  dba NorthShore Regional Health Centers

  • Federally Qualified Health Center (FQHC)
  • Merrillville, IN
  • NPI 1114257300
  Medicare reassignment NPD
• Obstetrical and Gynecological Associates, Inc

  • Obstetrics & Gynecology Physician
  • Valparaiso, IN
  • NPI 1912045345
  Medicare reassignment NPD
• Northshore Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • East Chicago, IN
  • NPI 1336992999
  NPD
• Northshore Health Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Portage, IN
  • NPI 1407061336
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1556236800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664323200000",
    "number": "1295399178",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10260 191ST ST STE 100",
            "city": "MOKENA",
            "state": "IL",
            "postal_code": "604488802",
            "telephone_number": "708-572-7669",
            "fax_number": "708-422-4253"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10260 191ST ST STE 100",
            "city": "MOKENA",
            "state": "IL",
            "postal_code": "604488802",
            "telephone_number": "708-572-7669",
            "fax_number": "708-422-4253"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "9730 S Western Ave",
            "address_purpose": "LOCATION",
            "city": "Evergreen Park",
            "state": "IL",
            "postal_code": "608052814",
            "country_code": "US",
            "telephone_number": "708-425-1907",
            "fax_number": "708-422-4253",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETROV",
        "first_name": "JACLYN",
        "middle_name": "MARY",
        "credential": "APN",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-04-26",
        "last_updated": "2022-09-28",
        "certification_date": "2022-09-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LX0001X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Obstetrics & Gynecology",
            "state": "IN",
            "license": "209.019158",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "APN LICENSE",
            "identifier": "209.019158",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACLYN",
            "last_name": "SERAFIN",
            "middle_name": "MARY",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Kate Perez
• Beth Peters
• Rebecca M Peters, SA
• Grace Petersen, M.S., SLP
• Beatrice Lynn Petrassi, DT
• Pharma Bio Inc
• Benjamin Phifer
• Phillip D. Narcissi DPM S.C. (Mokena Foot and Ankle Clinic)
• Sarah Phillips
• Physician Partners of Dupage

• Obstetrics & Gynecology Nurse Practitioner in Mokena, IL
• Providers in Mokena, IL by specialty
• Obstetrics & Gynecology Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.