Healthcare Provider Details

I. General information

NPI: 1881128155
Provider Name (Legal Business Name): JARED TYLER AHRENDSEN MD/PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N FAIRBANKS CT STE 2-454
CHICAGO IL
60611-3013
US

IV. Provider business mailing address

710 N FAIRBANKS CT STE 2-454
CHICAGO IL
60611-3013
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-3211
  • Fax: 312-694-1128
Mailing address:
  • Phone: 312-926-3211
  • Fax: 312-694-1128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036159617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: