Provider Demographics
NPI:1912932831
Name:ELLENS, JENNIFER L (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ELLENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4622
Mailing Address - Country:US
Mailing Address - Phone:630-469-0045
Mailing Address - Fax:630-469-0645
Practice Address - Street 1:444 N PARK BLVD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4622
Practice Address - Country:US
Practice Address - Phone:630-469-0045
Practice Address - Fax:630-469-0645
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363149833OtherTAX IDENTIFICATION NUMBER
IL487450OtherMEDICARE GROUP NUMBER
IL0222075OtherBLUE CROSS GROUP NUMBER
IL036103252Medicaid
IL080174264OtherMEDICARE RAILROAD
IL3631498336019001OtherCDPG HFS PAYEE ID
IL0222075OtherBLUE CROSS GROUP NUMBER
IL487450OtherMEDICARE GROUP NUMBER