Provider Demographics
NPI:1316974041
Name:ANDERSON, JACLYN KAY (DO, MS)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:KAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ABBOTT PARK RD
Mailing Address - Street 2:DEPT. R4NE, BLDG. AP34-2
Mailing Address - City:ABBOTT PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60064-6187
Mailing Address - Country:US
Mailing Address - Phone:847-938-0133
Mailing Address - Fax:
Practice Address - Street 1:200 ABBOTT PARK RD
Practice Address - Street 2:DEPT. R4NE, BLDG. AP34-2
Practice Address - City:ABBOTT PARK
Practice Address - State:IL
Practice Address - Zip Code:60064-6187
Practice Address - Country:US
Practice Address - Phone:847-938-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3715207R00000X
NE5874207RR0500X
IL036.125386207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26707OtherWELLMARK BCBS
IA0727701Medicaid
IAI18313Medicare PIN
IA26707OtherWELLMARK BCBS