1700848462 NPI number — RENATA M JENKIN MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700848462 NPI number — RENATA M JENKIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKIN
Provider First Name:
RENATA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700848462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 SKOKIE BLVD STE 475
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-7930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-272-4433
Provider Business Mailing Address Fax Number:
847-272-4434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 SKOKIE BLVD STE 475
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60062-7930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-272-4433
Provider Business Practice Location Address Fax Number:
847-272-4434
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  036148052 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0296575 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1700848462 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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