Provider Demographics
NPI:1326659962
Name:MOSES, JACQUELINE OLUWAKEMI (MS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:OLUWAKEMI
Last Name:MOSES
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S INDIANA AVE UNIT 1804
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 S INDIANA AVE UNIT 1804
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4738
Practice Address - Country:US
Practice Address - Phone:925-550-9750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071011251103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical