Basic Information
| Provider Information | |||||||||
| NPI: | 1003194796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZDON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZDON | ||||||||
| OtherFirstName: | JACKIE | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4400 W 95TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464040 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 95TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464040 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2011 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085-004090 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 2832-023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1003194796 | 05 | WI | MEDICAID |