MEDICARE: DR. JENNIFER MELISSA POWELL MD

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	207Q00000X	Family Medicine Physician	036110704	IL

General Provider Information

NPI Number	:	1124131966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MELISSA POWELL MD

Provider Business Mailing Address
First Line	:	3761 N STATE ROUTE 1 17
Second Line	:
City	:	MOMENCE
State	:	IL
Zip	:	60954-2400
Country	:	US
Telephone Number	:	815-472-3923
Fax Number	:	815-472-2816

Provider Business Practice Location Address
First Line	:	3761 N STATE ROUTE 1 17
Second Line	:
City	:	MOMENCE
State	:	IL
Zip	:	60954-2400
Country	:	US
Telephone Number	:	815-472-3923
Fax Number	:	815-472-2816

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	11/08/2021

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