Healthcare Provider Details

I. General information

NPI: 1235138579
Provider Name (Legal Business Name): VENKATA C JAMPALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 PARK AVE E
PRINCETON IL
61356-2537
US

IV. Provider business mailing address

20374 W BUCKTHORN CT
MUNDELEIN IL
60060-3319
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-4531
  • Fax: 309-623-2299
Mailing address:
  • Phone: 937-475-7809
  • Fax: 309-623-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036063756
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: