Healthcare Provider Details

I. General information

NPI: 1174533673
Provider Name (Legal Business Name): LESLIE N. JABINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

820 S WOOD ST 440 CSN, MC 718
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-355-0549
  • Fax: 312-413-0243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036090758
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036090758
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: