Provider Demographics
NPI:1407939630
Name:JESPERSEN, ROBERT CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CARL
Last Name:JESPERSEN
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 1:5701 N SHERIDAN RD
Mailing Address - Street 2:#28-S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4771
Mailing Address - Country:US
Mailing Address - Phone:773-989-5429
Mailing Address - Fax:
Practice Address - Street 1:625 SLAWIN CT
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2183
Practice Address - Country:US
Practice Address - Phone:847-789-7155
Practice Address - Fax:847-789-7161
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070086208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300267780OtherPTAN
IL036070086Medicaid
IL0001627310OtherBCBS
ILF300267780OtherPTAN