Provider Demographics
NPI:1669524369
Name:KURTH, JENNIFER LYNN (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KURTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 REVERE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1590
Mailing Address - Country:US
Mailing Address - Phone:773-301-7476
Mailing Address - Fax:
Practice Address - Street 1:60 REVERE DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1590
Practice Address - Country:US
Practice Address - Phone:773-301-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361132832084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113283OtherILLINOIS STATE LICENSE