Provider Demographics
NPI:1972531507
Name:JESSEN, MELANIE R (DO)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:JESSEN
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 1:7411 LAKE ST
Mailing Address - Street 2:SUITE 1120
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1876
Mailing Address - Country:US
Mailing Address - Phone:708-488-1490
Mailing Address - Fax:708-488-2394
Practice Address - Street 1:7411 LAKE ST
Practice Address - Street 2:SUITE 1120
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1876
Practice Address - Country:US
Practice Address - Phone:708-488-1490
Practice Address - Fax:708-488-2394
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-086145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF84985Medicare UPIN