MEDICARE: MS. JACQUELINE MOSES BROWN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	041324679	IL
2	163W00000X	Registered Nurse	041324679	IL

General Provider Information

NPI Number	:	1699976803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACQUELINE MOSES BROWN

Provider Business Mailing Address
First Line	:	6223 S EBERHART AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-3318
Country	:	US
Telephone Number	:	773-203-2490
Fax Number	:	773-288-5239

Provider Business Practice Location Address
First Line	:	6223 S EBERHART AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-3318
Country	:	US
Telephone Number	:	773-203-2490
Fax Number	:	773-288-5239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	01/30/2017

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