Provider Demographics
NPI:1275706285
Name:BERNARD, JENNIFER BACALLA (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BACALLA
Last Name:BERNARD
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 1:1900 W POLK ST STE 816
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-0540
Mailing Address - Fax:
Practice Address - Street 1:11700 W 2ND PL STE 210E
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1704
Practice Address - Country:US
Practice Address - Phone:720-321-8460
Practice Address - Fax:720-321-8461
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336079056207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism