Provider Demographics
NPI:1073189825
Name:JABER, MALLACK (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLACK
Middle Name:
Last Name:JABER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E ONTARIO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3284
Mailing Address - Country:US
Mailing Address - Phone:312-694-7000
Mailing Address - Fax:312-926-6274
Practice Address - Street 1:211 E ONTARIO ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3284
Practice Address - Country:US
Practice Address - Phone:312-694-7000
Practice Address - Fax:312-926-6274
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant