Provider Demographics
NPI:1235519901
Name:PENDERGAST, JAYNEE ELLISE (DO)
Entity Type:Individual
Prefix:
First Name:JAYNEE
Middle Name:ELLISE
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JAYNEE
Other - Middle Name:ELLISE
Other - Last Name:KRIPPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:1345 EDWARDS ST STE 2
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1692
Practice Address - Country:US
Practice Address - Phone:815-942-1421
Practice Address - Fax:815-488-2033
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125066219390200000X
IL036144109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.144109OtherIL LICENSE