Provider Demographics
NPI:1205220597
Name:SIWAK, JENNAH LAHOOD (MD)
Entity Type:Individual
Prefix:
First Name:JENNAH
Middle Name:LAHOOD
Last Name:SIWAK
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 1:1475 E BELVIDERE RD
Mailing Address - Street 2:APPT 301
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2012
Mailing Address - Country:US
Mailing Address - Phone:309-645-9904
Mailing Address - Fax:
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:PAVILLION C, SUITE 385
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030
Practice Address - Country:US
Practice Address - Phone:847-926-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125066997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036146355OtherLICENSE