Provider Demographics
NPI:1275072522
Name:JAHODA, KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:JAHODA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:MARCINKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:STE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:15474 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48170-4893
Practice Address - Country:US
Practice Address - Phone:734-355-6103
Practice Address - Fax:734-404-5317
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008119363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical