Healthcare Provider Details

I. General information

NPI: 1003044892
Provider Name (Legal Business Name): JACQUELINE ALEXANDRIA KHORASANEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 N MICHIGAN AVE SUITE 1058A
CHICAGO IL
60611-2826
US

IV. Provider business mailing address

259 E ERIE ST SUITE 100
CHICAGO IL
60611-2930
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-4756
  • Fax:
Mailing address:
  • Phone: 312-926-9512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125056134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: