Provider Demographics
NPI:1811578891
Name:CHENG, JEANETTE Y
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:Y
Last Name:CHENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 HARVESTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6686
Mailing Address - Country:US
Mailing Address - Phone:773-702-1150
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC1052
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125077585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program