Provider Demographics
NPI:1336115583
Name:JENTEL, JACQUES J (MD)
Entity Type:Individual
Prefix:MR
First Name:JACQUES
Middle Name:J
Last Name:JENTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W. 31ST STREET
Mailing Address - Street 2:SUITE 400 CREDENTIALING / SUITE 300 ADMINISTRATIVE
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1801 S. HIGHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148
Practice Address - Country:US
Practice Address - Phone:630-627-4722
Practice Address - Fax:630-627-9134
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095183207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095183Medicaid
IL036095183Medicaid