Provider Demographics
NPI:1457881351
Name:MACDONALD, JACLYN (DMD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6747 W HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2218
Mailing Address - Country:US
Mailing Address - Phone:708-712-6727
Mailing Address - Fax:
Practice Address - Street 1:2214 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3221
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031141122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist