Provider Demographics
NPI:1437407517
Name:JESSIE L MABAQUIAO MD
Entity Type:Organization
Organization Name:JESSIE L MABAQUIAO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RATCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-239-9600
Mailing Address - Street 1:855 W 103RD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2357
Mailing Address - Country:US
Mailing Address - Phone:773-239-9600
Mailing Address - Fax:773-239-9601
Practice Address - Street 1:855 W 103RD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2357
Practice Address - Country:US
Practice Address - Phone:773-239-9600
Practice Address - Fax:773-239-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-21
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360822322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082232Medicaid
IL036082232Medicaid