Provider Demographics
NPI:1063843670
Name:NEPOMUCENO, JENIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENIE
Middle Name:
Last Name:NEPOMUCENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 W MEDICAL CENTER DR STE A102
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8436
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE B207
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8439
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082689207R00000X, 208M00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082689Medicaid