Provider Demographics
NPI:1235386236
Name:MATCZAK, JENNIFER LYNNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:MATCZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 ANTHONY ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4419
Mailing Address - Country:US
Mailing Address - Phone:312-371-2540
Mailing Address - Fax:
Practice Address - Street 1:450 W HIGHWAY 22
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1919
Practice Address - Country:US
Practice Address - Phone:847-381-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics