Healthcare Provider Details

I. General information

NPI: 1831165034
Provider Name (Legal Business Name): TIMOTHY E JESSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 FAIRWAY DR
FREEPORT IL
61032-6600
US

IV. Provider business mailing address

421 W EXCHANGE ST PO BOX 268
FREEPORT IL
61032-4030
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6930
  • Fax: 815-599-7613
Mailing address:
  • Phone: 815-599-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036077588
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036077588
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: