Basic Information
Provider Information
NPI: 1588058606
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KANNAN
FirstName: JACQUELINE
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: VAIDYA
OtherFirstName: JACQUELINE
OtherMiddleName: L
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: BOX 78534
Address2:  
City: MILWAUKEE
State: WI
PostalCode: 532788534
CountryCode: US
TelephoneNumber: 8153989491
FaxNumber: 8153817498
Practice Location
Address1: 4119 W SHAMROCK LN
Address2:  
City: MCHENRY
State: IL
PostalCode: 600508268
CountryCode: US
TelephoneNumber: 8153989491
FaxNumber: 8153817498
Other Information
ProviderEnumerationDate: 03/26/2015
LastUpdateDate: 12/21/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/21/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RR0500X036-152551ILY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology

ID Information
IDTypeStateIssuerDescription
12507307305IL MEDICAID


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