Provider Demographics
NPI:1750762472
Name:JORDENS, TESALIA R (DO)
Entity type:Individual
Prefix:
First Name:TESALIA
Middle Name:R
Last Name:JORDENS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TESALIA
Other - Middle Name:R
Other - Last Name:RENTERIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:1550 HOBBS DR
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2027
Practice Address - Country:US
Practice Address - Phone:262-740-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68755207Q00000X
IL125.067595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100079046Medicaid