Healthcare Provider Details

I. General information

NPI: 1083641427
Provider Name (Legal Business Name): JEFFREY M MJAANES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 400
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1 WESTBROOK CORPORATE CTR #240
WESTCHESTER IL
60154-5701
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-4244
  • Fax: 312-942-1517
Mailing address:
  • Phone: 708-236-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number036107254
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: