Provider Demographics
NPI:1508469289
Name:STAYBACK, JACLYN ELIZABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ELIZABETH
Last Name:STAYBACK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ELIZABETH
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2241 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7636
Mailing Address - Country:US
Mailing Address - Phone:847-657-0096
Mailing Address - Fax:847-904-1351
Practice Address - Street 1:2241 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7636
Practice Address - Country:US
Practice Address - Phone:847-657-0096
Practice Address - Fax:847-904-1351
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.301052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist