Provider Demographics
NPI:1013422260
Name:MA, JACQUELINE S (CNM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:MA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4511
Mailing Address - Country:US
Mailing Address - Phone:773-254-1400
Mailing Address - Fax:312-829-6375
Practice Address - Street 1:966 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4511
Practice Address - Country:US
Practice Address - Phone:773-254-1400
Practice Address - Fax:312-829-6375
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017787367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife