Provider Demographics
NPI:1245483940
Name:DR JACQUELINE BARDWELL LTD
Entity type:Organization
Organization Name:DR JACQUELINE BARDWELL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-736-1555
Mailing Address - Street 1:4403 W LAWRENCE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2513
Mailing Address - Country:US
Mailing Address - Phone:773-736-1555
Mailing Address - Fax:773-736-1552
Practice Address - Street 1:4403 W LAWRENCE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2513
Practice Address - Country:US
Practice Address - Phone:773-736-1555
Practice Address - Fax:773-736-1552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071838Medicaid
IL036071838Medicaid