MEDICARE: JACQULYN MERCEDES MAURA

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1659721686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQULYN MERCEDES MAURA

Provider Business Mailing Address
First Line	:	4015 ROBERTS RD
Second Line	:	SUITE H
City	:	ISLAND LAKE
State	:	IL
Zip	:	60042-8506
Country	:	US
Telephone Number	:	708-305-0651
Fax Number	:

Provider Business Practice Location Address
First Line	:	4015 ROBERTS RD
Second Line	:	SUITE H
City	:	ISLAND LAKE
State	:	IL
Zip	:	60042-8506
Country	:	US
Telephone Number	:	708-305-0651
Fax Number	:

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

Provider Enumeration Date	:	06/21/2016
Last Update Date	:	06/21/2016

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