Provider Demographics
NPI:1013113265
Name:PACACCIO, JENNIFER JO (DPM)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JO
Last Name:PACACCIO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:SUESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:2180 OAKLAND DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3122
Mailing Address - Country:US
Mailing Address - Phone:815-669-4811
Mailing Address - Fax:815-986-6062
Practice Address - Street 1:2180 OAKLAND DR
Practice Address - Street 2:UNIT A
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3122
Practice Address - Country:US
Practice Address - Phone:815-669-4811
Practice Address - Fax:815-986-6062
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005347213E00000X
VA0103300964213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005347Medicaid
ILK44431Medicare PIN
ILIL2535001Medicare PIN