Provider Demographics
NPI:1003044892
Name:KHORASANEE, JACQUELINE ALEXANDRIA (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALEXANDRIA
Last Name:KHORASANEE
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 1:259 E ERIE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2930
Mailing Address - Country:US
Mailing Address - Phone:312-926-9512
Mailing Address - Fax:
Practice Address - Street 1:645 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1058A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2826
Practice Address - Country:US
Practice Address - Phone:312-503-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056134207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine