Basic Information
| Provider Information | |||||||||
| NPI: | 1083142202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHO-ESCALANTE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHO | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | SEZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | BELOIT HEALTH SYSTEM-BELOIT CLINIC | ||||||||
| Address2: | 1905 E. HUEBBE PARKWAY | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642293 | ||||||||
| FaxNumber: | 6083645452 | ||||||||
| Practice Location | |||||||||
| Address1: | BELOIT CLINIC | ||||||||
| Address2: | 1905 E. HUEBBE PARKWAY | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642240 | ||||||||
| FaxNumber: | 6083637394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2017 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-152177 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 125070459 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 73158-21 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100099230 | 05 | WI | MEDICAID |