Healthcare Provider Details

I. General information

NPI: 1740591619
Provider Name (Legal Business Name): JENNIFER MARIE DELUKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MAIN ST
TAYLORVILLE IL
62568-1668
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-287-8855
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax: 217-528-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036132596
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: