Provider Demographics
NPI:1508979345
Name:LENOX, JACK W (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:LENOX
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1235 N MULFORD RD
Mailing Address - Street 2:STE 200
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-965-6644
Mailing Address - Fax:815-965-2901
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:STE 200
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-965-6644
Practice Address - Fax:815-965-2901
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2020-12-27
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Provider Licenses
StateLicense IDTaxonomies
IL03608164207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03608164Medicaid
10100643OtherBLUECROSS
10100643OtherBLUECROSS
IL03608164Medicaid