Provider Demographics
NPI:1548228661
Name:PE, JEAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:
Last Name:PE
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 1:1302 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:209-956-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40943207L00000X
IL036-164719207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00352317OtherRAILROAD MEDICARE
CA00A409430OtherBLUE SHIELD OF CA
CA00A409430Medicaid
CA00A409432Medicare PIN
A62231Medicare UPIN
CA00A409430Medicaid