MEDICARE: JACQUELINE FRAZIER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	18315	HI

General Provider Information

NPI Number	:	1245788256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE FRAZIER

Provider Business Mailing Address
First Line	:	1110 W 50TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-5036
Country	:	US
Telephone Number	:	614-397-0931
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 W 50TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-5036
Country	:	US
Telephone Number	:	614-397-0931
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2016
Last Update Date	:	09/19/2016

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