Provider Demographics
NPI:1528540143
Name:KNIGHTLY, JACQUELINE MARY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARY
Last Name:KNIGHTLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10448 S SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3714
Mailing Address - Country:US
Mailing Address - Phone:773-633-7460
Mailing Address - Fax:
Practice Address - Street 1:11000 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5504
Practice Address - Country:US
Practice Address - Phone:708-346-0698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.221869183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist