Basic Information
| Provider Information | |||||||||
| NPI: | 1205220597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIWAK | ||||||||
| FirstName: | JENNAH | ||||||||
| MiddleName: | LAHOOD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1475 E BELVIDERE RD | ||||||||
| Address2: | APPT 301 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600302012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096459904 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1475 E BELVIDERE RD | ||||||||
| Address2: | PAVILLION C, SUITE 385 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479260106 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 125066997 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036146355 | 01 | IL | LICENSE | OTHER |