Provider Demographics
NPI:1225272172
Name:SCHIEBOUT, JESSEN DEAN
Entity Type:Individual
Prefix:
First Name:JESSEN
Middle Name:DEAN
Last Name:SCHIEBOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 S INDIANA AVE UNIT 2811
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-5171
Mailing Address - Country:US
Mailing Address - Phone:847-361-4492
Mailing Address - Fax:
Practice Address - Street 1:1423 CHICAGO RD
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3400
Practice Address - Country:US
Practice Address - Phone:708-709-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.098086207P00000X
IL036130861207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056594Medicaid
OH0056594Medicaid