Healthcare Provider Details

I. General information

NPI: 1033994322
Provider Name (Legal Business Name): JACQUELINE ANGELINA ROLA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SKOKIE BLVD STE 150
NORTHBROOK IL
60062-4038
US

IV. Provider business mailing address

243 W NORTH AVE
CHICAGO IL
60610-1236
US

V. Phone/Fax

Practice location:
  • Phone: 847-497-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011785
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: