Provider Demographics
NPI:1023390176
Name:VELASCO, JACQUELINE PENA (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:PENA
Last Name:VELASCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2501
Mailing Address - Country:US
Mailing Address - Phone:217-383-3088
Mailing Address - Fax:217-383-4468
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2501
Practice Address - Country:US
Practice Address - Phone:217-383-3088
Practice Address - Fax:217-383-4468
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036166076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics