Provider Demographics
NPI:1295046332
Name:RUSINAK, JACQUELINE THEODORA (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:THEODORA
Last Name:RUSINAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:T
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:836 W WELLINGTON AVE STE 1725
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:773-296-7054
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE STE 1725
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.133066207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine