Healthcare Provider Details

I. General information

NPI: 1245490812
Provider Name (Legal Business Name): JENNIFER M WOODWARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER FERNANDEZ

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 18-200
CHICAGO IL
60611-5929
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 18-200
CHICAGO IL
60611-5929
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-4525
  • Fax: 312-695-6007
Mailing address:
  • Phone: 312-695-4525
  • Fax: 312-695-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010-00328
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2010-00328
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2010-00328
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036137819
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: