Provider Demographics
NPI:1619020583
Name:COFFEY, JERI JANNINE (DDS)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:JANNINE
Last Name:COFFEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:JERI
Other - Middle Name:JANNINE
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2494
Mailing Address - Country:US
Mailing Address - Phone:708-442-0115
Mailing Address - Fax:708-442-8192
Practice Address - Street 1:24 WOODSIDE RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2494
Practice Address - Country:US
Practice Address - Phone:708-442-0115
Practice Address - Fax:708-442-8192
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-176021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19-17602OtherSTATE OF IL PROVIDER LISC