Provider Demographics
NPI:1205220597
Name:SIWAK, JENNAH LAHOOD (MD)
Entity type:Individual
Prefix:
First Name:JENNAH
Middle Name:LAHOOD
Last Name:SIWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-8637
Mailing Address - Country:US
Mailing Address - Phone:309-367-4144
Mailing Address - Fax:
Practice Address - Street 1:901 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:IL
Practice Address - Zip Code:61548-8637
Practice Address - Country:US
Practice Address - Phone:309-367-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036146355207Q00000X
IL125066997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036146355OtherLICENSE