Provider Demographics
NPI:1679853295
Name:BURKAT, JACQUELINE ROSE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:BURKAT
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 1:1211 N LASALLE ST APT 1002
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1978
Mailing Address - Country:US
Mailing Address - Phone:219-776-4302
Mailing Address - Fax:
Practice Address - Street 1:1554 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5550
Practice Address - Country:US
Practice Address - Phone:773-667-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-291940183500000X
IN26022668A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist