Provider Demographics
NPI:1376707364
Name:ENNIS, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:ENNIS
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 1:2250 W CAMPBELL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3502
Mailing Address - Country:US
Mailing Address - Phone:312-243-0600
Mailing Address - Fax:312-243-3297
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:SUITE #3D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-355-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113891207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology