Provider Demographics
NPI:1942243555
Name:PENK, JAMIE SMITH (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:SMITH
Last Name:PENK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 W LELAND AVE
Mailing Address - Street 2:APT 3E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5028
Mailing Address - Country:US
Mailing Address - Phone:773-577-3782
Mailing Address - Fax:
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-880-4335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238558208000000X
IL036.117924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics