Healthcare Provider Details

I. General information

NPI: 1255325676
Provider Name (Legal Business Name): JEROME ANTOUN JABBOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 YORK ST SUITE 2 C
BLUE ISLAND IL
60406-2411
US

IV. Provider business mailing address

600 N MCCLURG CT 3806 A
CHICAGO IL
60611-3044
US

V. Phone/Fax

Practice location:
  • Phone: 773-809-3622
  • Fax: 773-409-8659
Mailing address:
  • Phone: 248-802-3842
  • Fax: 248-802-3842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01060708A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036119492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: