Healthcare Provider Details

I. General information

NPI: 1063863462
Provider Name (Legal Business Name): JACQUELINE RAE MOLINA BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 S CICERO AVE
OAK LAWN IL
60453-2536
US

IV. Provider business mailing address

2127 W MADISON ST APT 301
CHICAGO IL
60612-5626
US

V. Phone/Fax

Practice location:
  • Phone: 773-644-7787
  • Fax: 224-241-3132
Mailing address:
  • Phone: 872-333-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-22785
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: