Provider Demographics
NPI:1124131966
Name:POWELL, JENNIFER MELISSA (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MELISSA
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3761 N STATE ROUTE 1 17
Mailing Address - Street 2:
Mailing Address - City:MOMENCE
Mailing Address - State:IL
Mailing Address - Zip Code:60954-2400
Mailing Address - Country:US
Mailing Address - Phone:815-472-3923
Mailing Address - Fax:815-472-2816
Practice Address - Street 1:3761 N STATE ROUTE 1 17
Practice Address - Street 2:
Practice Address - City:MOMENCE
Practice Address - State:IL
Practice Address - Zip Code:60954-2400
Practice Address - Country:US
Practice Address - Phone:815-472-3923
Practice Address - Fax:815-472-2816
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036110704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine