Provider Demographics
NPI:1669118386
Name:MICHAEL, JACQUELINE ROSE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ROSE
Other - Last Name:MADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:298 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4203
Mailing Address - Country:US
Mailing Address - Phone:630-938-3300
Mailing Address - Fax:
Practice Address - Street 1:298 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4203
Practice Address - Country:US
Practice Address - Phone:630-938-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.083840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine