Provider Demographics
NPI:1750736195
Name:SULLIVAN, JESSICA A (DPM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:SIERADZKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1250 W LAKE ST
Mailing Address - Street 2:STE 16
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-5744
Mailing Address - Country:US
Mailing Address - Phone:630-543-3000
Mailing Address - Fax:
Practice Address - Street 1:1250 W LAKE ST
Practice Address - Street 2:STE 16
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-5744
Practice Address - Country:US
Practice Address - Phone:630-543-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005718213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery