Provider Demographics
NPI:1619042124
Name:HALL-DAVIS, JACQUELYN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:HALL-DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N 64 TH STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3809
Mailing Address - Country:US
Mailing Address - Phone:618-397-0900
Mailing Address - Fax:618-397-0093
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-397-0900
Practice Address - Fax:618-397-0093
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360802702084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3649OtherBCBS MO
IL036080270Medicaid
ILG36399Medicare UPIN
MO3649OtherBCBS MO