Healthcare Provider Details

I. General information

NPI: 1356117253
Provider Name (Legal Business Name): JACLYN LEIBFORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

1242 W HURON ST APT 1
CHICAGO IL
60642-0036
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209.028063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: