Healthcare Provider Details

I. General information

NPI: 1235386236
Provider Name (Legal Business Name): JENNIFER LYNNE MATCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W HIGHWAY 22 MEDICAL STAFF OFFICE
BARRINGTON IL
60010-1919
US

IV. Provider business mailing address

415 ANTHONY ST
GLEN ELLYN IL
60137-4419
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-9600
  • Fax:
Mailing address:
  • Phone: 312-371-2540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.128871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: