Healthcare Provider Details

I. General information

NPI: 1932190634
Provider Name (Legal Business Name): JACQUELINE D WHITE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17901 GOVERNORS HWY STE 102
HOMEWOOD IL
60430-1144
US

IV. Provider business mailing address

17901 GOVERNORS HWY STE 102
HOMEWOOD IL
60430-1144
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-8880
  • Fax: 708-799-8991
Mailing address:
  • Phone: 708-799-8880
  • Fax: 708-799-8991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: