Provider Demographics
NPI:1689669293
Name:BELLUCCI JACKSON, JENNIFER M (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BELLUCCI JACKSON
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:PO BOX 6037
Mailing Address - Street 2:431 W LIBERTY ST
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-6037
Mailing Address - Country:US
Mailing Address - Phone:847-526-2151
Mailing Address - Fax:847-526-2017
Practice Address - Street 1:431 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2452
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:847-526-2017
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083207Medicaid
F26238Medicare UPIN
IL036083207Medicaid
ILL39213Medicare PIN