Provider Demographics
NPI:1659982585
Name:O'BRIEN, JACQUELINE JOANN (PHARM D)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JOANN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 S 16150W RD
Mailing Address - Street 2:
Mailing Address - City:BUCKINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60917-2105
Mailing Address - Country:US
Mailing Address - Phone:815-573-1170
Mailing Address - Fax:
Practice Address - Street 1:104 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9097
Practice Address - Country:US
Practice Address - Phone:217-586-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist