Healthcare Provider Details

I. General information

NPI: 1336003524
Provider Name (Legal Business Name): JACQUELYNN FALANA DOUGLAS-PETTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8205 S WINCHESTER AVE
CHICAGO IL
60620-5340
US

IV. Provider business mailing address

8205 S WINCHESTER AVE
CHICAGO IL
60620-5340
US

V. Phone/Fax

Practice location:
  • Phone: 708-800-9620
  • Fax:
Mailing address:
  • Phone: 708-800-9620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-319753
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: