Basic Information
| Provider Information | |||||||||
| NPI: | 1013422260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296375 | ||||||||
| Practice Location | |||||||||
| Address1: | 966 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 3128296375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2017 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 209017787 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.