Healthcare Provider Details

I. General information

NPI: 1831355346
Provider Name (Legal Business Name): JENNA C PODJASEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA C PETSCHKE

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 159TH ST SUITE A
OAK FOREST IL
60452-2776
US

IV. Provider business mailing address

6320 159TH ST SUITE A
OAK FOREST IL
60452-2776
US

V. Phone/Fax

Practice location:
  • Phone: 708-687-3855
  • Fax: 708-444-2324
Mailing address:
  • Phone: 708-687-3855
  • Fax: 708-444-2324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52031
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number52031
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036-133212
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: