Provider Demographics
NPI:1639564115
Name:JESSE, JOHN NICHOLAS III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NICHOLAS
Last Name:JESSE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2950 N SHERIDAN RD APT 1108
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-0952
Mailing Address - Country:US
Mailing Address - Phone:708-341-3893
Mailing Address - Fax:458-217-7768
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-3563
Practice Address - Fax:458-217-7768
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1572672085B0100X, 2085N0904X, 2085R0202X
WI67902-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639564115Medicaid