Healthcare Provider Details

I. General information

NPI: 1922739341
Provider Name (Legal Business Name): JENNIFER MORENO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 W OGDEN AVE
CHICAGO IL
60623-2426
US

IV. Provider business mailing address

600 S PAULINA ST
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 872-233-7681
  • Fax:
Mailing address:
  • Phone: 312-942-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125080514
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: