Provider Demographics
NPI:1093875171
Name:THOMPSON-FERNANDEZ, JACQUELINE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:A
Last Name:THOMPSON-FERNANDEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SEQUOIA TRL
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2016
Mailing Address - Country:US
Mailing Address - Phone:630-212-3143
Mailing Address - Fax:
Practice Address - Street 1:109 FAIRFIELD WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1583
Practice Address - Country:US
Practice Address - Phone:630-351-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice