Provider Demographics
NPI:1326933532
Name:MITZNER, JACQUELINE (BA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MITZNER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 W BIRCHWOOD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1748
Mailing Address - Country:US
Mailing Address - Phone:802-304-3007
Mailing Address - Fax:
Practice Address - Street 1:1925 N CLYBOURN AVE STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7395
Practice Address - Country:US
Practice Address - Phone:773-697-8839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program