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General NPI Number Information
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NPI Number | 1417460502
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Entity Type | Individual
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Provider Name | JAY DECLARADOR
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Gender | Male
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Dates
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Enumeration Date | 11/10/2017
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Last Update Date | 11/10/2017
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Provider Practice Location Address
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Address Line | 332 S MICHIGAN AVE
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City | CHICAGO
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State | IL
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Zip | 60604-4434
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Country | US
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Telephone | 888-660-4425
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Fax |
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Provider Business Mailing Address
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Address Line | 5450 ASTOR LN APT 418
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City | ROLLING MEADOWS
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State | IL
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Zip | 60008-4116
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Country | US
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Telephone | 847-259-7173
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209016591
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License Number State | IL
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