Provider Demographics
NPI:1316113954
Name:CHEN, JACKSON W (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:W
Last Name:CHEN
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 1:209 INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2797
Mailing Address - Country:US
Mailing Address - Phone:760-717-1412
Mailing Address - Fax:760-918-0960
Practice Address - Street 1:209 INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2797
Practice Address - Country:US
Practice Address - Phone:760-717-1412
Practice Address - Fax:760-918-0960
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047434208D00000X
CAC50725208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021606157OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
ILD10209Medicare UPIN
IL245-850Medicare PIN