Provider Demographics
NPI:1275989808
Name:SHASTRY, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:SHASTRY
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 1:111 W WASHINGTON ST STE 1801
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3430
Mailing Address - Country:US
Mailing Address - Phone:312-695-8106
Mailing Address - Fax:312-694-1340
Practice Address - Street 1:111 W WASHINGTON ST STE 1801
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3430
Practice Address - Country:US
Practice Address - Phone:312-695-8106
Practice Address - Fax:312-694-1340
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036152257207N00000X
IL125069308207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology