Provider Demographics
NPI:1245490812
Name:WOODWARD, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 18-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5929
Mailing Address - Country:US
Mailing Address - Phone:312-695-4525
Mailing Address - Fax:312-695-6007
Practice Address - Street 1:675 N SAINT CLAIR ST STE 18-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5929
Practice Address - Country:US
Practice Address - Phone:312-695-4525
Practice Address - Fax:312-695-6007
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00328207Q00000X, 207QG0300X, 207RG0300X
IL036137819207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917147Medicaid
NC149513OtherLICENSE
SCNC1352Medicaid
NC5917147Medicaid
NCNC0372DMedicare PIN