Provider Demographics
NPI:1265073100
Name:OWENS, JACQUELINE (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:OWENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 PATRIOT BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8021
Mailing Address - Country:US
Mailing Address - Phone:847-729-5510
Mailing Address - Fax:847-729-5512
Practice Address - Street 1:3633 W LAKE AVE STE 406
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5804
Practice Address - Country:US
Practice Address - Phone:847-729-5510
Practice Address - Fax:847-729-5512
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11164103T00000X
IL71010274103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist