Provider Demographics
NPI:1336866169
Name:MASANGCAY, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MASANGCAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4926 CRAIN ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-5444
Mailing Address - Country:US
Mailing Address - Phone:847-466-7069
Mailing Address - Fax:630-283-0343
Practice Address - Street 1:121 FAIRFIELD WAY STE 106B
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1555
Practice Address - Country:US
Practice Address - Phone:630-283-0393
Practice Address - Fax:847-466-7068
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3001932374U00000X, 376J00000X
ILINH2202079376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3001932OtherIDPH LICENSE