Basic Information
| Provider Information | |||||||||
| NPI: | 1003044892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHORASANEE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ALEXANDRIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129269512 | ||||||||
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| Practice Location | |||||||||
| Address1: | 645 N MICHIGAN AVE | ||||||||
| Address2: | SUITE 1058A | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125034756 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 125056134 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.