Provider Demographics
NPI:1487829867
Name:REA, JACQUELINE GRACE (PHD, ABPP-CN)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:GRACE
Last Name:REA
Suffix:
Gender:F
Credentials:PHD, ABPP-CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 W 143RD ST STE 37
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1940
Mailing Address - Country:US
Mailing Address - Phone:800-564-0863
Mailing Address - Fax:
Practice Address - Street 1:10730 W 143RD ST STE 37
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-1940
Practice Address - Country:US
Practice Address - Phone:800-564-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007463103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent