Healthcare Provider Details

I. General information

NPI: 1508956707
Provider Name (Legal Business Name): JONDELLE B. JENKINS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 E 87TH ST
CHICAGO IL
60617-2740
US

IV. Provider business mailing address

1706 E 87TH ST
CHICAGO IL
60617-2740
US

V. Phone/Fax

Practice location:
  • Phone: 773-374-5300
  • Fax: 773-374-5860
Mailing address:
  • Phone: 773-374-5300
  • Fax: 773-374-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number016003520
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016003520
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number016003520
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016003520
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003520
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: