Provider Demographics
NPI:1003194796
Name:ZDON, JACQUELINE ROSE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:ZDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JACKIE
Other - Middle Name:R
Other - Last Name:ZDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-346-4040
Practice Address - Fax:708-346-3287
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-004090363AS0400X
WI2832-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003194796Medicaid