=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225612096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAYDIENNE PAULISA CRUZ FONTEJON DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2021
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E 22ND ST STE 205
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-953-8088
-----------------------------------------------------
Fax | 630-953-8094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 E 22ND ST STE 205
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-953-8088
-----------------------------------------------------
Fax | 630-953-8094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 016006055
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------