Healthcare Provider Details

I. General information

NPI: 1083455430
Provider Name (Legal Business Name): JACQUELINE SIELAFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3258 W 111TH ST
CHICAGO IL
60655-2729
US

IV. Provider business mailing address

3700 W 115TH PL
ALSIP IL
60803-6206
US

V. Phone/Fax

Practice location:
  • Phone: 773-629-8217
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209029794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: