Provider Demographics
NPI:1871560623
Name:O'LEARY, MINNA JINN (MD)
Entity type:Individual
Prefix:
First Name:MINNA
Middle Name:JINN
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINNA
Other - Middle Name:DESIREE
Other - Last Name:JINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636
Mailing Address - Country:US
Mailing Address - Phone:309-495-1670
Mailing Address - Fax:708-216-9033
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636
Practice Address - Country:US
Practice Address - Phone:309-495-1670
Practice Address - Fax:708-216-9033
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361076062084P0800X
IL0361076062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36107606Medicaid
IL36107606Medicaid
ILK11312Medicare ID - Type Unspecified
ILK11311Medicare ID - Type Unspecified