Provider Demographics
NPI:1942311972
Name:BERRY, JENNETTE LATRESE (MD)
Entity Type:Individual
Prefix:
First Name:JENNETTE
Middle Name:LATRESE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNETTE
Other - Middle Name:LATRESE
Other - Last Name:BRISTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20110 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:10242 S VINCENNES AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1301
Practice Address - Country:US
Practice Address - Phone:773-238-1676
Practice Address - Fax:773-238-1641
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111987Medicaid
P00266812OtherR/R MEDICARE
P00266812OtherR/R MEDICARE