Provider Demographics
NPI:1114776697
Name:CALDERON, JACQUELINE CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CHRISTINE
Last Name:CALDERON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 N KEATING AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3306
Mailing Address - Country:US
Mailing Address - Phone:847-946-9402
Mailing Address - Fax:
Practice Address - Street 1:6708 N KEATING AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-3306
Practice Address - Country:US
Practice Address - Phone:847-946-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085010547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program