Provider Demographics
NPI:1467425215
Name:PICKETT, JAY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:PICKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:509 HAMACHER ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1592
Mailing Address - Country:US
Mailing Address - Phone:618-939-3939
Mailing Address - Fax:618-939-3941
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-3939
Practice Address - Fax:618-939-3941
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 081291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081291Medicaid
ILL50856Medicare PIN
D42332Medicare UPIN