Healthcare Provider Details

I. General information

NPI: 1528056801
Provider Name (Legal Business Name): JENNIFER DEVANEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 E BELVIDERE RD STE 106
GRAYSLAKE IL
60030-2076
US

IV. Provider business mailing address

1170 E BELVIDERE RD MUNDELEIN PEDIATRICS #106
GRAYSLAKE IL
60030-2061
US

V. Phone/Fax

Practice location:
  • Phone: 847-548-7337
  • Fax: 847-548-9909
Mailing address:
  • Phone: 847-548-7337
  • Fax: 847-548-9909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036101023
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: