Provider Demographics
NPI:1699173542
Name:JACQUELYN HALL-DAVIS,M.D. LTD
Entity type:Organization
Organization Name:JACQUELYN HALL-DAVIS,M.D. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-622-9240
Mailing Address - Street 1:1669 WINDHAM WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3072
Mailing Address - Country:US
Mailing Address - Phone:618-622-9240
Mailing Address - Fax:618-622-9241
Practice Address - Street 1:1669 WINDHAM WAY
Practice Address - Street 2:SUITE B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3072
Practice Address - Country:US
Practice Address - Phone:618-622-9240
Practice Address - Fax:618-622-9241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360802702084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL540653OtherTRICARE
IL036080270Medicaid
IL036080270Medicaid
ILG36399Medicare UPIN