Provider Demographics
NPI:1972722007
Name:DZIEDZIC, JACQUELINE MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:CAPPIELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:BUILDING 101, ROOM 1752
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:BUILDING 101, ROOM 1752
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016781207P00000X
IL036127802207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine