Provider Demographics
NPI:1194039669
Name:JACKOWSKI, MICHELLE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:JACKOWSKI
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:4201 WINFIELD RD FL 4
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4025
Mailing Address - Country:US
Mailing Address - Phone:331-221-6377
Mailing Address - Fax:331-221-2357
Practice Address - Street 1:1200 S YORK ST STE 4120
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5630
Practice Address - Country:US
Practice Address - Phone:331-221-9009
Practice Address - Fax:331-221-2750
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008236367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBSIL
IL950150OtherMEDICARE GROUP
IL12129852OtherCAQH