Healthcare Provider Details

I. General information

NPI: 1346770336
Provider Name (Legal Business Name): JESSICA WYKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 JOLIET RD
COUNTRYSIDE IL
60525-4642
US

IV. Provider business mailing address

6410 JOLIET RD
COUNTRYSIDE IL
60525-4642
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-4448
  • Fax: 708-352-1052
Mailing address:
  • Phone: 708-352-4448
  • Fax: 708-352-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125070594
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-152800
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: