Healthcare Provider Details

I. General information

NPI: 1689802282
Provider Name (Legal Business Name): JACARA KELLEY-MUHAMMAD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR ST STE 101
MELROSE PARK IL
60160-4100
US

IV. Provider business mailing address

14 LAKE ST
OAK PARK IL
60302-2606
US

V. Phone/Fax

Practice location:
  • Phone: 708-406-3040
  • Fax:
Mailing address:
  • Phone: 708-383-0113
  • Fax: 708-383-9911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125057077
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036131286
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: