Provider Demographics
NPI:1629243456
Name:SIMMONS, JERRYL JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:JERRYL
Middle Name:JOHNSON
Last Name:SIMMONS
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 1:9119S EXCHANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4225
Mailing Address - Country:US
Mailing Address - Phone:773-768-5000
Mailing Address - Fax:
Practice Address - Street 1:2012 S AUSTRIAN PINE ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3876
Practice Address - Country:US
Practice Address - Phone:708-712-3802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070465208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics