Healthcare Provider Details

I. General information

NPI: 1639984990
Provider Name (Legal Business Name): JORDYN GREENBAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125088440
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: