Provider Demographics
NPI:1134117344
Name:BELICENA, JONETTE P (MD)
Entity Type:Individual
Prefix:
First Name:JONETTE
Middle Name:P
Last Name:BELICENA
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 1:301 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6590
Mailing Address - Country:US
Mailing Address - Phone:815-725-0007
Mailing Address - Fax:815-725-4579
Practice Address - Street 1:301 MADISON ST STE 120
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6652
Practice Address - Country:US
Practice Address - Phone:815-725-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091730208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091730Medicaid
IL036091730Medicaid