Provider Demographics
NPI:1053064741
Name:PETKOVIC, JACQUELINE (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PETKOVIC
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 N LAKE SHORE DR APT 3505
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6478
Mailing Address - Country:US
Mailing Address - Phone:847-830-2229
Mailing Address - Fax:
Practice Address - Street 1:355 E ERIE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3167
Practice Address - Country:US
Practice Address - Phone:312-238-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.437627163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse