Basic Information
| Provider Information | |||||||||
| NPI: | 1245308048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 VOLLMER RD. | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084818883 | ||||||||
| FaxNumber: | 7084812917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036099212 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036099212 | 05 | IL | MEDICAID | 200258980 | 05 | IN | MEDICAID |