Provider Demographics
NPI:1073899548
Name:MIS, JACLYN L (PAC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:L
Last Name:MIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:L
Other - Last Name:CROWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:708-388-5672
Practice Address - Street 1:17495 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7581
Practice Address - Country:US
Practice Address - Phone:815-416-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant