Healthcare Provider Details

I. General information

NPI: 1447215033
Provider Name (Legal Business Name): JASON CORY TJADEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N RANDALL RD
LAKE IN THE HILLS IL
60156-5961
US

IV. Provider business mailing address

301 N RANDALL RD
LAKE IN THE HILLS IL
60156-5961
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-6065
  • Fax: 847-658-6136
Mailing address:
  • Phone: 847-658-6065
  • Fax: 847-658-6136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036109900
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-109-900
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: