Provider Demographics
NPI:1316170103
Name:NEAL, JACQUELINE DIANE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:NEAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S DAMEN AVE RM 2535
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3728
Mailing Address - Country:US
Mailing Address - Phone:312-569-6376
Mailing Address - Fax:312-569-8050
Practice Address - Street 1:820 S DAMEN AVE RM 2535
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-569-6376
Practice Address - Fax:312-569-8050
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055837208100000X
IL036-132962208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036132962-1Medicaid