Provider Demographics
NPI:1275713588
Name:MARSIDI, JENNIFER (DO)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:MARSIDI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W JACKSON BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3227
Mailing Address - Country:US
Mailing Address - Phone:312-942-3254
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 215
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3227
Practice Address - Country:US
Practice Address - Phone:312-942-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.077691208000000X, 207R00000X
WAAP30007951363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8868973Medicare Oscar/Certification
WAG8899027Medicare UPIN