Provider Demographics
NPI:1558999185
Name:JUNA, JACQUELINE SUZANNE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUZANNE
Last Name:JUNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:16985 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5909
Practice Address - Country:US
Practice Address - Phone:262-641-8400
Practice Address - Fax:262-784-3804
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.076543207V00000X
WI84304207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100285608Medicaid