Provider Demographics
NPI:1013512243
Name:AJIDE, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:AJIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 W GRANVILLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3008
Mailing Address - Country:US
Mailing Address - Phone:773-627-4247
Mailing Address - Fax:
Practice Address - Street 1:977 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1400
Practice Address - Country:US
Practice Address - Phone:847-367-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041342473363LF0000X
IL209022486363LF0000X
IL209022466363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily