Provider Demographics
NPI:1164740254
Name:DELACRUZ, JENNIFER ANNE REGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE REGAN
Last Name:DELACRUZ
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 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-7400
Mailing Address - Fax:630-933-4168
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-7400
Practice Address - Fax:630-933-4168
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056188207R00000X
IL036132162207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036132162OtherMEDICAID
IL206147OtherMEDICARE PTAN GROUP
ILF400230237OtherMEDICARE PTAN INDIVIDUAL