Healthcare Provider Details

I. General information

NPI: 1700752730
Provider Name (Legal Business Name): JAKUB JAN SKORUPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2025
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

692 ESSINGTON RD UNIT A
JOLIET IL
60435-4903
US

IV. Provider business mailing address

8001 W LELAND AVE
NORRIDGE IL
60706-4450
US

V. Phone/Fax

Practice location:
  • Phone: 815-247-4911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019037197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: