Provider Demographics
NPI:1972009124
Name:LIZZO, JENNA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:LIZZO
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:DEPT ANESTHESIOLOGY
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:800-862-9980
Practice Address - Fax:314-362-1185
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036154383207LC0200X, 207LC0200X
MO2023013141207LC0200X
IAMD-48039207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200123353Medicaid