MEDICARE: MS. JESSICA KATHRYN SARGESON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019032369	IL

General Provider Information

NPI Number	:	1013579226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA KATHRYN SARGESON

Provider Business Mailing Address
First Line	:	350 N CLARK ST STE 600
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-4782
Country	:	US
Telephone Number	:	312-274-4580
Fax Number	:

Provider Business Practice Location Address
First Line	:	12200 WESTERN AVE STE 108
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-1493
Country	:	US
Telephone Number	:	708-385-3700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2019
Last Update Date	:	08/29/2019

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