Provider Demographics
NPI:1659721686
Name:MAURA, JACQULYN MERCEDES
Entity Type:Individual
Prefix:
First Name:JACQULYN
Middle Name:MERCEDES
Last Name:MAURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 ROBERTS RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-8506
Mailing Address - Country:US
Mailing Address - Phone:708-305-0651
Mailing Address - Fax:
Practice Address - Street 1:4015 ROBERTS RD
Practice Address - Street 2:SUITE H
Practice Address - City:ISLAND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60042-8506
Practice Address - Country:US
Practice Address - Phone:708-305-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker