Provider Demographics
NPI:1295399178
Name:PETROV, JACLYN MARY (APN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARY
Last Name:PETROV
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARY
Other - Last Name:SERAFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10260 191ST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8802
Mailing Address - Country:US
Mailing Address - Phone:708-572-7669
Mailing Address - Fax:708-422-4253
Practice Address - Street 1:10260 191ST ST STE 100
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8802
Practice Address - Country:US
Practice Address - Phone:708-572-7669
Practice Address - Fax:708-422-4253
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN209.019158363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.019158OtherAPN LICENSE