Provider Demographics
NPI:1437505492
Name:BACCHUS, JANNAH FAIZA (DPM)
Entity Type:Individual
Prefix:
First Name:JANNAH
Middle Name:FAIZA
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15349 WEST AVE
Mailing Address - Street 2:APT 3NW
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5328
Mailing Address - Country:US
Mailing Address - Phone:260-580-3677
Mailing Address - Fax:
Practice Address - Street 1:8101 HINSON FARM RD STE 301
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3405
Practice Address - Country:US
Practice Address - Phone:703-560-3773
Practice Address - Fax:703-799-0050
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301270213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery