Healthcare Provider Details

I. General information

NPI: 1558743559
Provider Name (Legal Business Name): JENNIFER WOODRUFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARSHALLA MD

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453
US

IV. Provider business mailing address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5375
  • Fax:
Mailing address:
  • Phone: 708-684-5375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.066307
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-145728
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: