Provider Demographics
NPI:1750407714
Name:PAYTON, JACQUELINE ELISE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ELISE
Last Name:PAYTON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-5641
Mailing Address - Fax:314-362-0369
Practice Address - Street 1:4320 FOREST PARK AVE
Practice Address - Street 2:DIV PA LAB AND GENOMIC MED, STE 209
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2979
Practice Address - Country:US
Practice Address - Phone:314-362-5641
Practice Address - Fax:314-362-0369
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008022583207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200118891Medicaid