Healthcare Provider Details

I. General information

NPI: 1366259731
Provider Name (Legal Business Name): JACQUELINE WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 HOME AVE
STICKNEY IL
60402-4316
US

IV. Provider business mailing address

4400 HOME AVE
STICKNEY IL
60402-4316
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-4500
  • Fax:
Mailing address:
  • Phone: 708-783-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1813573
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: