Provider Demographics
NPI:1902366412
Name:BIESIADECKI, JENNIFER CRYSTAL (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CRYSTAL
Last Name:BIESIADECKI
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 1:1037 DES PLAINES AVE APT 507
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2152
Mailing Address - Country:US
Mailing Address - Phone:815-508-9320
Mailing Address - Fax:
Practice Address - Street 1:540 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1173
Practice Address - Country:US
Practice Address - Phone:574-946-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02006838A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program