Healthcare Provider Details

I. General information

NPI: 1407939630
Provider Name (Legal Business Name): ROBERT CARL JESPERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SLAWIN CT
MOUNT PROSPECT IL
60056-2183
US

IV. Provider business mailing address

5701 N SHERIDAN RD #28-S
CHICAGO IL
60660-4771
US

V. Phone/Fax

Practice location:
  • Phone: 847-789-7155
  • Fax: 847-789-7161
Mailing address:
  • Phone: 773-989-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036070086
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036070086
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: