Provider Demographics
NPI:1790309508
Name:SARANTAKOS, JENNA (DO)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:SARANTAKOS
Suffix:
Gender:F
Credentials:DO
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-744-6589
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:414-744-6589
Practice Address - Fax:414-747-8848
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81205207Q00000X
IAR-11880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100246712Medicaid