MEDICARE: JACQUELINE CARSON

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	174H00000X	Health Educator

General Provider Information

NPI Number	:	1285165191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE CARSON

Provider Business Mailing Address
First Line	:	PO BOX 1337
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-0337
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 DES PLAINES AVE APT 505
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-1442
Country	:	US
Telephone Number	:	708-434-0456
Fax Number	:

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

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	03/22/2017

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Directions to “ JACQUELINE CARSON ” Practice Location

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