Healthcare Provider Details

I. General information

NPI: 1164784559
Provider Name (Legal Business Name): JESSICA STOWE O'CONNELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST 03-2304
CHICAGO IL
60611-2914
US

IV. Provider business mailing address

250 E SUPERIOR ST 03-2304
CHICAGO IL
60611-2914
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-4673
  • Fax: 312-472-4687
Mailing address:
  • Phone: 312-472-4673
  • Fax: 312-472-4687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036140339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: