Provider Demographics
NPI:1174572911
Name:JEAN-JACQUES, WILFRID (MD)
Entity type:Individual
Prefix:
First Name:WILFRID
Middle Name:
Last Name:JEAN-JACQUES
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:PO BOX 3312
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-3312
Mailing Address - Country:US
Mailing Address - Phone:773-731-0890
Mailing Address - Fax:773-731-0889
Practice Address - Street 1:2315 E 93RD ST
Practice Address - Street 2:SUITE 426
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3936
Practice Address - Country:US
Practice Address - Phone:773-731-0890
Practice Address - Fax:773-731-0889
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056671207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL684890Medicare PIN
ILD93889Medicare UPIN