Healthcare Provider Details

I. General information

NPI: 1518329481
Provider Name (Legal Business Name): JACQUELINE WILNEFF PONCZEK M.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

2950 N SHERIDAN RD APT 802
CHICAGO IL
60657-0951
US

V. Phone/Fax

Practice location:
  • Phone: 800-543-7362
  • Fax:
Mailing address:
  • Phone: 847-436-0847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036148403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: