Provider Demographics
NPI:1912056326
Name:FERNALD, JORGE E (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:E
Last Name:FERNALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 W COLLEGE DR
Mailing Address - Street 2:SUITE #101
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1152
Mailing Address - Country:US
Mailing Address - Phone:708-448-8470
Mailing Address - Fax:
Practice Address - Street 1:7300 W COLLEGE DR
Practice Address - Street 2:SUITE #101
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:708-448-8470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0855262084P0800X
IL036-0955262084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095526Medicaid
ILF400488988OtherMEDICARE